Comparative-Effectiveness Advocates Vow Better Outcomes Will Follow

An increase from the federal stimulus law in the relatively tiny funding that already exists for comparative effectiveness research is expected to expand the information that clinicians can integrate into their practices. But the new money raises more questions about what should be studied and how to disseminate the information gleaned.

How those new questions are answered is particularly important for people with mental illness because of the dearth of data examining alternative treatments for psychiatric conditions and inconsistencies in care for particular ilnesses. Mental health experts gathered at the 25th Annual Rosalynn Carter Symposium on Mental Health Policy in Atlanta in November noted that research has found that people with mental illness frequently receive substandard care for their psychiatric conditions.

“We have had historically a major challenge in translating scientific advances into practice,” said Carolyn Clancy, M.D., director of the federal Agency for Healthcare Research and Quality (AHRQ).

The widespread implementation of comparative effectiveness research (CER) in the mental health field can help determine which treatments work best for which patients and “how we can make the right thing to do the easy thing to do,” she said.

Clancy and other federal health officials hope to shorten the lag time in translating research into usable and accessible clinical information through a recent burst in federal funding, including $1.1 billion for CER included in the Obama administration's stimulus legislation (PL 111-05). The Fiscal 2009 federal budget provided AHRQ with $372 million for such research, and “substantially more” CER funding may come through the health care legislation Congress is considering.

Although the funding is small when compared with over $2 trillion in overall annual spending on health care, it is the largest amount to date in an area that many consider crucial to lowering health care costs and improving patient health.

“There are more and more diagnostic and therapeutic situations where we have multiple options, and that's a fabulous place to be,” Clancy said. “What we haven't had is comparative information that lets clinicians and patients figure out what is actually the best option for this individual based on different benefits or harms associated with each treatment.”

One area in which some of the new funding is focused, Clancy said, is research on treatments for patients suffering from co-occurring general psychiatric conditions and substance abuse. The research also will delve into ways to integrate mental health care into general health care more effectively.

Barriers Must Be Overcome

Advocates for CER hope the expanded federal support for such research will help minimize some of the fears that opponents raised when they tried to block its funding.

CER opponents claimed that the studies would inevitably lead to government domination of the doctor-patient relationship and health care rationing. Similar objections have been raised to proposed panels in health care reform bills that would examine the evidence to recommend best practices.

Clancy said CER efforts could actually expand choice by focusing on research that is “descriptive not proscriptive.” Better informed treatment options would come from initiatives such as the inclusion of larger numbers of minorities in research and studies to identify the effects of drugs in specific populations.

“Right now clinicians and patients are making decisions under conditions of enormous uncertainty,” she said.

The potential to improve patient outcomes through better information made widely available to clinicians has garnered the support of private industry, said Hyong Un, M.D., national medical director of behavioral health for Aetna Health Plans, at the Carter Center symposium. His company's research has found that inconsistencies in mental health care allowed a small percentage of chronically ill patients to drive a majority of the company's health care costs.

“We're at a point where we need to do something, because we can't sustain the current pattern,” he said.

New Approaches Needed

The additional research on treatment options will not be able to meet its stated aim of improving mental health care treatment outcomes, however, unless it includes a range of options, maintain some mental health experts.

For psychiatrist Daniel Fisher, M.D., Ph.D., those options should include patient-centered care and the use of “patient peers” in treatment. He said that his research on alternatives to the “terrible and traumatizing experience” of hospitalization for people with serious mental illness has found that the use of community-based settings with trained peer-support personnel and psychiatrist oversight can provide effective alternatives for a fraction of the cost of institutional care.

“Beyond the finances, it helps people find their road to recovery,” Fisher said.

Such care is one of a growing number of peer-focused treatments that have been developed in recent years. However, peer-based treatment will never be widely adopted in the mental health arena if it doesn't also attract the research support to validate its value.

“At this point, the evidence, you might say, is our own lives,” said Fisher, who said he has received treatment for a psychiatric disorder.

Nico Pronk, Ph.D., a senior research investigator at Healthpartners Research Foundation, agreed that CER will need to include alternative-treatment approaches beyond just traditional medical interventions. One example he cited was research that showed that financial incentives were as effective as pharmacological interventions in smoking cessation.

Other effective therapeutic approaches, including medical homes in mental health care and phone-based therapies, also appear promising but lack comparative studies matched with conventional treatments, said the mental health experts.

Clancy said at least some of the new federal CER funds are likely to be devoted to such newer “holistic life approaches” in mental health treatment, which currently lack standard models that would allow other mental health professionals to replicate them effectively in other locations.

Further information on the Carter Center Mental Health Program is posted at <www.cartercenter.org>.