Interest In Comparative Effectiveness Research Research Articles

Who Can Respond to Treatment?

Interest in comparative effectiveness research and the rising number of negative or "small effect" trials have stimulated research into differential response to treatment among subgroups of patients. To develop and test the Potential for Benefit Scale (PBS), a composite measure to identify subgroups of patients with differential potential for response to treatment, using diabetes as a model. Cross-sectional and longitudinal cohort study. Type 2 diabetes patients (n = 1361) were identified from 7 outpatient clinics serving a diverse population. Of these, 611 completed a 1-year follow-up. To represent patients' health status, we used the Total Illness Burden Index, the Physical Function Index of the SF-36, the Center for Epidemiologic Studies Depression Scale, and the Diabetes Burden Scale. To represent personality characteristics related to health, we used the Provider-Dependent Health Care Orientation scale. We assessed the contribution of these measures to a composite scale of patients' potential for treatment response in terms of self-reported medication adherence and glycemic control. Principal components analysis confirmed associations among these measures. The internal consistency reliability of the PBS was adequate (Cronbach alpha = 0.65). Patients in the lowest versus highest quartile of the PBS reported poorer adherence (18% vs. 55%, P < 0.001) and poorer glycemic control at baseline (mean hemoglobin A1c values: 7.75 vs. 7.39, P < 0.001). Those in the highest quartile of the PBS also were more likely to reach target values for glycemic control (HbA1c <7%) at 1-year follow-up, (adjusted OR = 1.61, P < 0.05). The PBS, a composite scale, may be helpful in identifying patients with differential potential for response to treatment.

Comparative Effectiveness Research Priorities at Federal Agencies: The View from the Department of Veterans Affairs, National Institute on Aging, and Agency for Healthcare Research and Quality

In the last year, attention has been focused on translating federally sponsored health research into better health for Americans. Since the passage of the American Recovery and Reinvestment Act (ARRA) on February 17, 2009, ARRA funds to support Comparative Effectiveness Research (CER) have increased this focus. A large proportion of topical areas of interest in CER affects the older segment of the population. The Department of Veterans Affairs (VA), the National Institute on Aging (NIA), and the Agency for Healthcare Research and Quality (AHRQ) have supported robust research portfolios focused on aging populations that meet the varying definitions of CER. This short article briefly describes the research missions of the AHRQ, NIA, and VA. The various definitions of CER as the Congressional Budget Office, the Institute of Medicine, and the ARRA-established Federal Coordinating Council have put forward, as well as important topics for which CER is particularly needed, are then reviewed. Finally, approaches in which the three agencies support CER involving the aging population are set forth and opportunities for future CER research outlined.

Examining Costs and Benefits in the Health Care Debate

Back to table of contents Next article Taking IssueFull AccessExamining Costs and Benefits in the Health Care DebateDavid Shern Ph.D.,David Shern Ph.D.Search for more papers by this author,Published Online:13 Jan 2015https://doi.org/10.1176/ps.2009.60.4.419AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Improving this country's very expensive and poorly performing health care system requires critical analysis of all health care expenditures and their attendant benefits. In a study reported in this issue, Valenstein and colleagues help frame the debate about costs and benefits of psychiatric care. These authors capitalized on the availability of comprehensive data from the VA health system to estimate the cost of implementing monitoring procedures that have been recommended by the FDA for reducing suicide risk in depression treatment.The authors estimate that the protocol would cost the VA system up to $270 million annually. Although this represents somewhat less than a 1% increase in the VA's health care budget, it is nonetheless a substantial sum. For example, it represents nearly half of annual federal expenditures for the Mental Health Block Grant, which helps to provide safety-net mental health services to the civilian population. The magnitude of the expense underlines the importance of understanding the validity of the FDA guidelines for preventing suicide and, perhaps, of the FDA's considering the costs of its recommended protocols in relation to anticipated benefits. Clearly, this admonition is relevant to the full spectrum of health care interventions, with treatments for psychiatric conditions being no more and no less important than other therapies. Some would criticize any consideration of cost in the face of a life-saving and clinically sensible intervention or would appropriately worry about including the cost of nonintervention. However, maximizing the efficient utilization of scarce health care resources requires that we understand all the costs and benefits.For these reasons, and given the elevated suicide risk for veterans and the expense of the FDA protocol, further research is needed. The availability of this large VA data set might provide the statistical power for a longitudinal, experimental analysis in which differing intensities of follow-up could be implemented with several samples and evaluated in relation to completed suicides or suicide attempts. Longitudinal research might also help to better identify individuals for whom this level of vigilance is merited and perhaps suggest a stepped approach to assessing suicidality with graded follow-up. Studies could investigate the use of automated methods to perform follow-up screening. Veterans would report their thoughts and feelings, which in some cases would trigger personal follow-up.Analysis of both costs and benefits must be part of the contemporary health care debate. Although recent congressional interest in comparative effectiveness research does not explicitly consider costs, it certainly anticipates such consideration. The cost analysis presented by Valenstein and colleagues highlights the importance of understanding differential effectiveness and of conducting research to develop evidence-based protocols that consider comprehensive costs as well as benefits.president and chief executive officer, Mental Health America FiguresReferencesCited byDetailsCited ByNone Volume 60Issue 4 April, 2009Pages 419-419PSYCHIATRIC SERVICES April 2009 Volume 60 Number 4 Metrics PDF download History Published online 13 January 2015 Published in print 1 April 2009