Physician Views on the Use of Comparative Effectiveness Data: A
Comparative Effectiveness Data: A National Surveyy
Salomeh Keyhani MD MPH
Salomeh
Keyhani MD MPH
James J. Peters VAMC
Mount Sinai School of Medicine
Acknowledgements
Co‐Investigators:
Alex Federman, MD MPH
Alex Federman, MD MPH Mark Woodward, PhD
This project was supported by a grant from This
project was supported by a grant from
the Robert Wood Johnson Foundation.
Background
• Comparative effectiveness research (CER) has been promoted as a vehicle to improve the p
p
quality and efficiency of practice.
• The inclusion of funding for CER in the stimulus bill of 2009 triggered a national debate over the appropriate role of evidence
debate over the appropriate role of evidence in health care. Background
• Rationing
Rationing of medical care
of medical care
• Intrusion of the government in the doctor‐
patient relationship
i
l i hi
• Loss of physician autonomy
p y
y
• Cookbook medicine
The Patient Protection and Affordable Care Act
• Omission
Omission of any mechanism to oblige of any mechanism to oblige
physicians to apply CER data in their clinical practice.
practice
• CER may not be used: as mandates, guidelines or recommendations for payment coverage or
or recommendations for payment, coverage or treatment decisions.
Objectives
• To
To examine physician
examine physician’ss views on the use of views on the use of
data generated from CER.
• To examine the characteristics of physicians p y
who demonstrated a more negative view towards the development and use of CER
towards the development and use of CER.
Methods Design
Methods‐Design
• A national, mailed survey of a random
sample
l off physicians
h i i
b
between
t
JJune 25th
and October, 31st 2009.
Methods Sample
Methods‐Sample
• Physician contact information was obtained from the AMA Physician M t fil
Master file, which contains data on all U.S. Physicians. hi h
t i d t
ll U S Ph i i
• This was a sub study of larger survey on coverage expansions
•
A random sample 1500 physicians from each of four specialty groups were surveyed (total, n=6000).
Groups:
• Primary care • Non‐surgical specialists N
i l
i li t
• Surgical specialists • Other specialists (e.g., radiologists, anesthesiologists, and pathologists). • 50% random selection of physicians included in a larger study of physicians’ views about health insurance expansion.
Methods Survey Development
Methods‐Survey Development
• We empanelled 7 nationally recognized physician p
y
g
p y
leaders and health policy and survey research experts.
• We drafted survey questions and asked the expert panel to rank these items in terms of importance. • We refined the content and survey questions through yq
g
cognitive interviews with 16 physicians representing 7 states, 10 specialties, and 4 types of practice settings ( l
(solo, group, free‐standing clinic, and hospital‐based f
di
li i
dh i l b d
clinic).
Methods Survey Development
Methods‐Survey Development
S
Survey Questions:
Q ti
1)
National guidelines should be developed to guide physician National
guidelines should be developed to guide physician
practice.
2)
If national guidelines are established, comparative effectiveness data should be used in their development.
3) CER data will be used to restrict my freedom to choose treatments for my patients.
4) The availability of CER data would improve the quality of care provided to patients.
Methods Analysis
Methods‐Analysis
 Excluded physicians in training and physicians from U.S. territories.
 Compared the characteristics of respondents and non‐respondents using d h h
f
d
d
d
data available in the AMA master file.  Reported the percentage of physicians that agree with each statement.
 Examined differences in agreement with the four items by physician characteristics using chi‐square statistics.  Grouped outcome variables as agree vs. disagree or uncertain
Methods Analysis
Methods‐Analysis
• Examined physician characteristics associated with a more negative view of CER. ti
i
f CER
• Considered
Considered physicians as having a more negative view of physicians as having a more negative view of
CER:
 If they agreed that CER would restrict freedom to choose treatment choices for their patients.
 Disagreed that it would improve quality of care. Disagreed that it would improve quality of care
• Multivariable logistic regression analysis to examine physician characteristics associated with a more negative h
h
d
h
view of CER.
Results: Responders vs. Non Responders
• 2
2416 eligible physicians received the survey with 6 li ibl h i i
i d h
ih
CER questions.
• Response rate 50.9%. p
• Survey
Survey respondents were slightly older than non‐
respondents were slightly older than non‐
respondents (52.0 vs. 50.2 years, p<0.001)
• No significant differences by gender, geographic l ti
location, specialty category, or type of practice.
i lt
t
t
f
ti
National Guidelines Should be Developed
to Guide Physician Practice
to Guide Physician Practice
60.0%
56.5%
50.0%
40.0%
31 2%
31.2%
30.0%
Agree
Unsure
Disagree
20.0%
12.1%
10.0%
0 0%
0.0%
If National Guidelines are Established, Comparative Effectiveness Data Should be Used in their
Effectiveness Data Should be Used in their Development
90.0%
80 0%
80.0%
77.8%
70.0%
60 0%
60.0%
Agree
50.0%
Uncertain
40 0%
40.0%
Disagree
30.0%
20 0%
20.0%
10.0%
0 0%
0.0%
11.9%
10.2%
Comparative Effectiveness data Will be Used to Restrict My Freedom to Choose Treatments
My Freedom to Choose Treatments
for My Patients
70.0%
65.7%
60.0%
50.0%
40 0%
40.0%
Agree
Uncertain
30.0%
20.0%
10 0%
10.0%
0.0%
Disagree
g
18.2%
15.9%
The Availability of Comparative Effectiveness D t
Data would Improve the Quality of Care ld I
th Q lit f C
Provided to Patients
60.0%
55.2%
50.0%
40 0%
40.0%
30.0%
20.0%
10 0%
10.0%
0.0%
Agree
28.0%
Uncertain
16.6%
Disagree
Results‐Agreement by Physician Characteristics
Physician Characteristics
Guidelines
Should be
Should be Developed
If Guidelines
Developed
Developed,
CER data Should be
Used
CER will Restrict My
Restrict My Freedom
CER will
Improve the
Improve the Quality of Care
Yes 50.3%
82.6%
71.6%
50.1%
No
64.2%
74.0%
58.3%
61.9%
Practice owner
Hours of Patient Care
>=20
53.9%
76.3%
67.7%
52.7%
<20
69.2%
84.9%
56.1%
67.9%
West
59.7%
83.3%
61.7%
60.1%
Northeast
63.1
80.7%
64.4%
57.8%
South
48.8%
70.7%
69.9%
48.7%
Midwest
58.0%
79.8%
65.1%
57.4%
Census Region
Results: A Negative View of CER
Results: A Negative View of CER
35.5% did not believe that CER would improve quality and also believed that it would restrict li
d l b li d h i
ld
i
a physician’s freedom to choose treatments for their patient.
Results‐Physician Characteristics Associated with a More Negative View of
Associated with a More Negative View of CER (N=1203)
Unadjusted Odds (95% CI)
Adjusted Odds (95% CI)
1.80 (1.39‐2.35)
1.59 (1.16‐2.19)
Practice owner
yes
No reference
reference
Hours of Patient Care
Hours of Patient Care
>=20
2.16 (1.48‐3.17)
1.96 (1.27‐3.02
<20 hours
reference
reference
West
0.84 (0.57‐1.24)
0.82 (0.54‐1.24)
Northeast
1.05 (0.70‐1.58)
South
1.01 (0.68‐1.49)
1.54 (1.09‐2.18)
Midwest
reference
reference
Census Region
1.52 (1.06‐2.17)
Adjusted for physician specialty, training (MD or DO), age, practice type, urban or rural location, and source of income
Limitations
•
Modest response rate
Modest response rate.
•
Other than age there were no statistically significant differences between non‐
p
p
respondents and respondents.
•
The extent to which physician respondents understood the purpose and potential use of CER is unclear but questions on CER were prefaced with the following information: information
“Comparative effectiveness research compares existing therapies or diagnostics used for the same condition (e.g., a beta‐blocker
used for the same condition (e.g., a beta
blocker vs. a diuretic to prevent heart vs. a diuretic to prevent heart
attack in patients with hypertension). Congress is considering the creation of national clinical guidelines using CER data.” •
The Patient Protection and Affordable Care Act
h
d ff d bl
d
does not mandate the d
h
development of guidelines or the use of CER in guidelines.
Conclusions
• A majority of physicians support the use of CER data and believe it will improve the p
quality of health care despite acknowledging that information derived from CER could be
that information derived from CER could be used to restrict treatment choices. • A
A sizable minority have negative views sizable minority have negative views
regarding the use of CER data.
Implications
• Language adapted into barring the use of CER in guidelines or in coverage decisions demonstrates fears regarding the implications of y
p
this research for industry as well as patients.
• Policymakers need to lay the foundation for the eventual use of CER data
CER data.
• Physicians’ support will play an important role in ensuring that comparative effectiveness research can live up to its promise of ti
ff ti
h
li
t it
i
f
improving the quality of care and reducing costs.
• Need to understand why a third of physicians hold an unfavorable view of CER.