Legislative News, Studies and Analysis - NCSL: Moving Toward a … · 2009. 1. 6. · • Cost of services must be considered • Priorities must be set • Some beneficial services

Center for Evidence-based PolicyGlobalizing Evidence, Localizing Decisions

The Role of Evidence-based Medicine in Quality

NCSL: Moving Toward a High Performance Health System

Health Policy Preconference

Mark Gibson, Deputy DirectorCenter for Evidence-based Policy

December 10, 2008Atlanta, Georgia


Reality Forms the Foundation

• Resources are limited• It is not IF we ration, but HOW• Not all health care services are equally

beneficial• Providing everything for someone (even

the less effective) usually means providing nothing for someone else (even the most effective)


The State Dilemma

States in political vise – Advocates and industry want maximum

service– Taxpayers want to limit expenditures

• Is healthcare or coverage the objective?• Isn’t health improvement really what we

want?• Evidence-based medicine can help


Focus on Health of Population Served

• Goal: Improving the health of the population to be served

• Health care is only helpful if it improves health

• What services actually work?• Which services help which patients?• How do we ensure the right service goes

to the right person at the right time?


What is Evidence Based Medicine?

“…evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”

David Sackett


Why is a Systematic Review Important?

• “Because the randomised trial, and especially the systematic review of several randomised trials, is so much more likely to inform us and so much less likely to mislead us, it has become the "gold standard" for judging whether a treatment does more good than harm.”

David Sackett

6


What Is Good Evidence?

• Systematic Review– Careful question formulation– Global search– Grading evidence– Synthesis of good evidence– Peer review– Full Disclosure


Why Are Systematic Reviews Helpful?

• “Four out of five studies showed that…”– How big were the studies?– What was their quality?– How big were the results?

• “Carvedilol superior to metropolol in preventing death in heart failure patients.”

• “We have a meta-analysis that shows that…”





Conclusions: During 6 weeks’ treatment, ziprasidone and olanzapine demonstrated comparable antipsychotic efficacy. Differences favoring ziprasidone were observed in metabolic parameters.

Simpson et al, 2004




What Is Good Evidence (cont.)

• Hierarchy of Evidence– Systematic Reviews– Randomized Controlled Trials– Observational Studies– Case Series

• Quality varies among all types of studies


Clinical Evidence on Drugs

• Drug Effectiveness Review Project (DERP)– 14 states and CADTH– Evidence-based Practice Centers provide

research– Fully transparent

• Open process• Public comment

– Use to make sure the best clinical info is considered


DERP Results

• Good evidence, no significant differences (PPIs)

• No good comparative evidence (Opiod Analgesics)

• Good evidence, marginal differences (Triptans)• Good evidence, significant clinical differences

(Beta Blockers)• Even classes with good evidence often have

significant gaps (subpopulations)


Clinical Evidence for Benefit Design andCoverage Decisions (MED)

• 11 states creating a collaboration• Access to off-the-shelf Tech Assessments• Evidence experts for real time consultation• $ to commission systematic reviews as needed• $ for additional technology assessments• Forecasting service and clearinghouse• Assistance in evaluating policy initiatives


MED Results

• Criteria for imaging • Rapid reviews of

– Vacuum wound therapy– Terbutaline pumps

• Durable medical equipment• Substance Abuse• Proton beam radiation therapy• Disease management


States Must Act

• Current economic downturn creates urgent fiscal challenge– Provider reimbursement– Eligibility– Whole categories of care

• National reform not certain (content and timing)• States have experience at fiscal decision making

not present in Washington DC• States are learning to use clinical evidence

(EBM) to guide and defend policy


A Possible Policy Construct (Eddy)

• Resources are limited• Cost of services must be considered• Priorities must be set• Some beneficial services won’t be provided• Objective is to maximize population health• All patients should be treated equitably• Determine priority on benefit, harm, and cost


Possible Policy Construct (continued)

• Empirical evidence should trump subjective• Criteria for treatment use

– Evidence that it is better than nothing for population– That it outweighs harms in improving health– Comparatively better than other treatment at

improving population health– When determining whether the treatment satisfies the

three criteria above, the burden of proof must lie with people advocating the use of a service

• Outcomes should reflect preference of patients


EBM is Foundation for Quality

•Knowing what works is the first step•Knowing who it works for is the second•Creating policy that ensures:

-We don’t pay for things whose harms exceed their benefit-We do pay for things that result in significant clinical benefit-We hold industry and the medical community accountable for what they provide to our patients


Contact Information

Mark Gibson, Deputy DirectorCenter for Evidence-based Policy

2611 SW 3rd Avenue, MQ 280Portland, Oregon 97201

[email protected]

www.ohsu.edu/policycenter

mailto:[email protected]

Documents

Legislative News, Studies and Analysis - NCSL: Moving Toward a … · 2009. 1. 6. · • Cost of services must be considered • Priorities must be set • Some beneficial services