I came across an interesting piece in a New York Times blog discussing the issues around comparative effectiveness studies. The researchers were lamenting that despite all the money and effort put into such studies, the results were having very little impact in the real world. There were tons of excuses as to why this was happening including the fact that the studies were not reflecting what was happening in real life. Physicians in the real world pointed out that the studies used ancillary things that were not available in most office practices. They talked about the changes being way too extreme based on currently accepted standards. Then of course, they blamed the reimbursement schemes and the pharmaceutical industry for promoting higher cost therapies. There is definitely no simple answer and I am not even sure they are close to understanding the issues.
A number of years ago I heard one of the country’s most respected cardiologists answering a question on how he would handle a particularly complicated yet common medical situation. He described how he would handle the case using only evidence based procedures that were pretty time consuming to implement. After the lengthy answer someone in the audience said that would be very difficult for an office based cardiologist to do. The speaker responded by saying that he was asked what he would do, working in a major medical center with a team of residents. He went on to say that if he had an office based practice he would do things exactly as they were doing then. There are so many variables.
I also think it is wrong to put the blame on our industry as to why there is not universal acceptance for the results of these studies. They talk about using diuretics to treat hypertension and all the money that could be saved. For almost all hypertension patients the choice is a generic not a branded product. The choice doctors are making are usually between several different classes of generics and the industry has very little impact. Likewise with PSA tests. If the medical world really bought into the concept of doing fewer PSA tests then that would happen.
Perhaps there needs to be a dose of reality here. Over the years we have seen this same thing play out with the economic studies we do for our products. Even though great care is taken to design trials that try to measure the overall costs and benefits of one therapy over the other if the results don’t match expectations or meet the audience’s needs they always find ways to show that the study is flawed.
Comparative studies are here to stay and as more and more medical care becomes protocol driven it is important to fully understand their strengths, weaknesses and how they will be viewed in the real world. It will always be easier to gain acceptance if the results of the study prove what most physicians think already. It will usually be easier to convince people that a less expensive currently used therapy is good enough relative to a much more expensive newer therapy. Single studies are interesting but must be validated with other studies and must withstand the test of time. The more complex the study, the tougher it will be to explain to the medical community. The bottom line is people like to see studies that prove they are doing the right thing.
Perhaps there is an even more important message here for pharmaceutical marketing. Getting a physician to accept a new therapy is much easier if it involves only a minor change from what they are doing. Even if the therapy is a breakthrough it should be described as just the next step to what they have done for years. The financials are very important in that it is easier to change if the costs are neutral or better. Simplicity will always beat complexity. Finally even the best, most compelling information takes time to sink in. Change takes time.