The policy debate over public investment in comparative effectiveness research

Discontinuing the Term "Stakeholder" From the NIA IMPACT Collaboratory Engaging Partners Team: An Example of the Process of Language Change in an Organization

In this paper, we describe our process of changing language of the National Institute on Aging Imbedded Pragmatic Alzheimer's disease and AD-related dementias Clinical Trials Collaboratory (NIA IMPACT Collaboratory) "Stakeholder Engagement Team" to "Engaging Partners Team" in response to feedback from community partners regarding the problematic connotations of the term "stakeholder." We present a brief history of the term "stakeholder" and its use in clinical and community-engaged research. Then, we summarize critiques of this term, including its colonial history and potential to reinforce complacency with generational traumas, particularly among Indigenous peoples and communities. We conclude with a detailed overview of our team and organization's multi-step process to discontinue use of the term "stakeholder," in alignment with a theoretical model of organizational behavior change. This paper highlights the importance of critically evaluating language and responding to community partners. We hope our process can guide other researchers and organizations.

Comparative effectiveness issues in lung cancer

Lung cancer accounts for more cancer deaths than breast, prostate, colorectal and pancreatic cancer combined. With an aging population, greater intensity of cancer care, and the need for care of the growing number of cancer survivors, comparative effectiveness research opportunities will continue to emerge for this disease. In this chapter, we focus on CER opportunities in lung cancer surgery from the vantage point of those factors directly influenced by the surgeon, patient and the healthcare system.

From comparative effectiveness research to patient-centered outcomes research: policy history and future directions

Containing growth in health care expenditures is considered to be essential to improving both the long-term fiscal outlook of the federal government and the future affordability of health care in the US. As health care expenditures have increased, so too have concerns about the quality of health care. Better information on the clinical effectiveness of alternative treatments and other interventions is needed to improve the quality of care and restrain growth in expenditures. This article explains the key role played by the federal government in defining the context and process of comparative effectiveness research as well as its funding. Subsequently, the article explores the mission, priorities, and research agenda of the Patient-Centered Outcomes Research Institute, which is an independent, nonprofit corporation established in 2010 by the Patient Protection and Affordable Care Act.

Comparative effectiveness research in cancer genomics and precision medicine: current landscape and future prospects

A major promise of genomic research is information that can transform health care and public health through earlier diagnosis, more effective prevention and treatment of disease, and avoidance of drug side effects. Although there is interest in the early adoption of emerging genomic applications in cancer prevention and treatment, there are substantial evidence gaps that are further compounded by the difficulties of designing adequately powered studies to generate this evidence, thus limiting the uptake of these tools into clinical practice. Comparative effectiveness research (CER) is intended to generate evidence on the "real-world" effectiveness compared with existing standards of care so informed decisions can be made to improve health care. Capitalizing on funding opportunities from the American Recovery and Reinvestment Act of 2009, the National Cancer Institute funded seven research teams to conduct CER in genomic and precision medicine and sponsored a workshop on CER on May 30, 2012, in Bethesda, Maryland. This report highlights research findings from those research teams, challenges to conducting CER, the barriers to implementation in clinical practice, and research priorities and opportunities in CER in genomic and precision medicine. Workshop participants strongly emphasized the need for conducting CER for promising molecularly targeted therapies, developing and supporting an integrated clinical network for open-access resources, supporting bioinformatics and computer science research, providing training and education programs in CER, and conducting research in economic and decision modeling.

The implications of comparative effectiveness research for academic medicine

With growing constraints on government spending, policy makers are investing in comparative effectiveness research (CER) to attempt to bring the power of science to bear on the problems of suboptimal outcomes and high cost in the U.S. health care system. This commitment of resources to CER reflects confidence that better evidence can help clinicians and patients make better decisions, consistent with the long tradition of medical schools' and teaching hospitals' use of science to inform medical care. Thus, CER offers a great opportunity, albeit with some considerable challenges, for academic medicine to play a central role in comprehensive health care reform. Certainly, many scientists conducting CER will learn their methodological rigor in the training programs of academic health centers. Numerous new CER research teams will be needed, establishing effective partnerships far outside the walls of the traditional academic setting. And the clinicians interpreting the medical literature and applying the insights from CER to the unique problems of individual patients will need to learn this evidence-based, patient-centered care from the educators, mentors, and role models at U.S. medical and other health science schools and teaching hospitals. Achieving this will require investment in research infrastructure, adaptations of institutional culture, development of new disciplines and research methods, establishment of new collaborations, training of new faculty, and the expansion and refocusing of educational capacity. By successfully responding to this challenge, academic medicine can further strengthen its long-standing commitment to the scientific practice of medicine and the use of evidence in patient-centered, personalized care.

The n-of-1 clinical trial: the ultimate strategy for individualizing medicine?

N-of-1 or single subject clinical trials consider an individual patient as the sole unit of observation in a study investigating the efficacy or side-effect profiles of different interventions. The ultimate goal of an n-of-1 trial is to determine the optimal or best intervention for an individual patient using objective data-driven criteria. Such trials can leverage study design and statistical techniques associated with standard population-based clinical trials, including randomization, washout and crossover periods, as well as placebo controls. Despite their obvious appeal and wide use in educational settings, n-of-1 trials have been used sparingly in medical and general clinical settings. We briefly review the history, motivation and design of n-of-1 trials and emphasize the great utility of modern wireless medical monitoring devices in their execution. We ultimately argue that n-of-1 trials demand serious attention among the health research and clinical care communities given the contemporary focus on individualized medicine.

The new era of comparative effectiveness: will public health end up left behind?

The Patient Protection and Affordable Care Act created the nation's first comprehensive comparative effectiveness research (CER) program. According to some optimistic accounts, CER will revolutionize clinical practice and transform the health care delivery system. But what about public health? There are reasons for concern that it could end up left behind in the new era of comparative effectiveness. This article analyzes the considerable promise and serious limitations of applying CER to public health. It also highlights important issues that will likely emerge for public health law and policy as the health care system transitions to greater reliance on CER.

Comparative effectiveness research and genomic medicine: an evolving partnership for 21st century medicine

The American Recovery and Reinvestment Act has provided resources for comparative effectiveness research that will lead to evidence-based decisions about health and health care choices. Some have voiced concerns that evidence-based comparative effectiveness research principles are only relevant to "average" patients and not as much to individuals with unique combinations of genes, exposures and disease outcomes, intrinsic to genomic medicine. In this commentary, we argue that comparative effectiveness research and genomic medicine not only can and should coexist but also they will increasingly benefit from each other. The promise and success of genomic medicine will depend on rigorous comparative effectiveness research to compare outcomes for genome-based applications in practice to traditional non-genome-based approaches. In addition, the success of comparative effectiveness research will depend on developing new methods and clinical research infrastructures to integrate genome-based personalized perspectives into point of care decisions by patients and providers. There is a need to heal the apparent schism between genomic medicine and comparative effectiveness research to enhance knowledge-driven practice of medicine in the 21st century.