Health care costs continue to rise, with significant geographic differences in spending on health care and outcomes within the United States. The goal of comparative effectiveness research is to reduce health care spending without adversely effecting overall health according to the Congressional Budget Office. There are unique challenges and barriers to applying comparative effectiveness research to radiology, including rapidly changing technology, complex multistep care processes, and the burden of proving the impact of a diagnostic exam on patient outcome. Radiology shares other challenges of acceptance of comparative effectiveness research results (diffusion of new knowledge and successful implementation of changes in clinical practice) with all of health care, but with the added complication that radiologists do not order radiology exams.
Over the past three decades, there has been great innovation and increased volume in medical imaging . Entire invasive procedures have been replaced by noninvasive imaging (eg, pneumoencephalography and head computed tomography [CT]). When 235 leading internists were surveyed to rank the innovations whose loss would have the most adverse effect on patients , five radiology procedures ranked in the top 12, with magnetic resonance imaging (MRI) and CT listed number one. Others listed in the top 12 included balloon angioplasty, mammography, and ultrasound. The growth in imaging technology was paralleled by the growth in imaging utilization and costs. Annual spending on diagnostic imaging increased from $220 to $419 per Medicare beneficiary between 2000 and 2006 .
Despite the belief in the benefit of medical imaging to patients, evidence-based research is needed to show that that a specific procedure has a benefit to a patient or population in a specific clinical setting. The American Reinvestment and Recovery Act budgeted $1.1 billion for comparative effectiveness research (CER). It established the Federal Coordinating Council for Comparative Effectiveness Research to direct the vision and priorities for CER conducted under all federal agencies. The council sees the purpose of CER research to improve health care decisions by reducing uncertainty when multiple treatment options are available. In 2009, the council defined CER as “the conduct and synthesis of research comparing the benefits and harms of different interventions and strategies to prevent, diagnose, treat and monitor health conditions in ‘real world’ settings. The purpose of this research is to improve health outcomes by developing and disseminating evidence-based information to patients, clinicians, and other decision makers, responding to their expressed needs, about which interventions are most effective for which patients under specific circumstances” .
The Institute of Medicine has established the top 100 priorities for CER and defined CER as “the generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat, and monitor a clinical condition or to improve the delivery of care. The purpose of CER is to assist consumers, clinicians, purchasers, and policy makers to make informed decisions that will improve health care at both the individual and population levels” .
These definitions acknowledge the multiple stakeholders in health care that would be expected to use the data of these studies as well as specifying real-world settings. They also establish the need to gather evidence-based medicine and disseminate it with the objective of improving health outcomes and the delivery of care. Also included in the definition of CER is the impact on individual patients as well as populations, which acknowledges personalized medicine.
However, in a 2007 report on CER, the Congressional Budget Office (CBO) described CER as an opportunity to constrain costs in both sectors (federal spending and private sector) without adverse health consequences. The rationale for this belief is based in part on the significant geographic variations in spending and clinical practices without clear improvement in life expectancy or other health statistics. The CBO suggested “that generating better information about the costs and benefits of different treatment options—through research on the comparative effectiveness of those options—could help reduce health care spending without adversely affecting health overall.”
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Use of comparative effectiveness research data
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Patient population
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Obstacles to comparative effectiveness research in radiology
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Changing patient behavior
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Conclusions
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