Analysis of Focus Group Findings Reveals Physician Concerns About Comparative Effectiveness Research

Comparative effectiveness research has become a pivotal term in Washington these days, particularly after the federal government passed the American Recovery and Reinvestment Act of 2009, which authorized $1.1 billion for comparative effectiveness research. Now an analysis of findings (17-page PDF; About PDFs) from six focus groups commissioned by the Medicare Payment Advisory Commission, or MedPAC, finds that although physicians think comparative effectiveness research studies are a good idea, their support for such studies depends on a number of factors.

"Those who were most supportive of (comparative effectiveness research) said it would give them more information to decide best treatments for their patients," said Joan Sokolovsky, Ph.D., a principal policy analyst at MedPAC, who presented the focus group findings during a September MedPAC meeting here. "Despite all of the information they receive on a daily basis, (physician participants) had very little access to head-to-head comparisons of drugs, devices or procedures," she said.

The focus groups were held in Baltimore, Chicago and Seattle and included 10-12 physicians in each group. Participants included primary care physicians and subspecialists, as well as physicians from solo and small-group practices, multispecialty groups, and hospitals. Primary care physicians comprised about half of the physicians in the groups, according to Sokolovsky.

Sokolovsky noted that physician participants who supported comparative effectiveness research emphasized transparency in such research because no source is completely unbiased. Researchers should not only report any conflicts of interest, but they also should incorporate their research designs, methodologies and results into their study reports so others can evaluate the studies and the outcomes for themselves, participants said.

Even the government could be biased toward less expensive treatments, said participants. Nevertheless, they added, the NIH, the FDA and the CDC generally are trusted sources of information. Participants also cited specialty societies as trusted sources of research information, including for information presented via conferences, journals or e-mail communications, said Sokolovsky. However, several focus group participants said the information they get from their specialty societies is consensus driven and not necessarily based on empirical evidence because the evidence does not always exist.

Nearly all of the physicians in the focus groups said information provided by pharmaceutical representatives was a good way to learn about new treatments.

"But they had to take the information they received with a grain of salt," said Sokolovsky. "If they were interested in a particular new treatment, then they would have to do more research to see if they were really interested."

Several participants said comparative effectiveness research studies should take into consideration not only outcomes but also treatment side effects, a patient's quality of life and differences among patient groups. However, other participants contended that if studies took all of those factors into account, they would require such large sample sizes that it would make the studies prohibitively expensive, said Sokolovsky.

Some participants also were concerned about the effects of comparative effectiveness research on innovation. Pharmaceutical and device manufacturers whose products are less effective could be driven out of business, thus slowing innovation in treatments, said participants. Others, however, noted that comparative effectiveness research likely would prompt manufacturers to develop more innovative products.

"We got very different views," said Sokolovsky.

In addition, some focus group participants linked comparative effectiveness research to liability reform and were concerned such research could make them vulnerable to lawsuits if they used alternative treatments, even if they could support their decisions with good clinical research. Other participants believed comparative effectiveness research would protect them from lawsuits if they could show they based their decisions on evidence-based medicine.

Not surprisingly, all of the physicians in the focus groups said they would not use a treatment that didn't work for their patients, according to Sokolovsky. But most physicians did not want to rely solely on personal experiences when making clinical decisions, she added. "For example, one physician noted that there were some things that an individual physician simply couldn't observe based only on their patients."

Conversely, opponents of comparative effectiveness research said their personal treatment experiences were sufficient for them to make treatment decisions. "One focus group participant said, 'I think the decisions should be left up to us. We have our judgment,'" Sokolovsky recounted.

Focus group participants also discussed the best ways to make information from comparative effectiveness studies useful. They believed that research findings should be concise, said Sokolovsky. "In other words, something they can look at quickly to see if it is relevant to their practice and then dig deeper if they are interested."

Similarly, said Sokolovsky, results should be easily accessible. "Several (participants) said (comparative effectiveness research) priorities should be high-priced new technologies, with studies done before these technologies become widely diffused practice."

Participants also said there should be an emphasis on studies that compare medical management with procedural therapies for a given condition, and others said it is important to update studies frequently to take into account new evidence because of the quick pace of medical science, according to Sokolovsky.

The most ardent opponents of comparative effectiveness research were concerned that government-led comparative effectiveness research would lead to mandatory guidelines from the government and private payers, said Sokolovsky. These physicians said they received all the information they needed from annual conferences, journals, pharmaceutical company representatives and their own experiences, she added.

Others expressed concern that the research would show only which treatments, on average, were most effective and would ignore treatments required by or most beneficial in certain subpopulations.