IOM panel seeks program to evaluate research, guidelines

Buried in clinical guidelines and buffeted by the latest published research findings, what's a physician to do when faced with a patient and a 15-minute treatment window? Begin to sort through the conflicting guidelines or analyze the latest research studies?

A Jan. 24 Institute of Medicine report suggests a way to bring order from the chaos that surrounds conflicting clinical guidelines and questions about how to choose the best available diagnostic, treatment or preventive service -- but Congress would have to create a federal program to make it happen.

Physicians and medical researchers who drafted the IOM report recommend that the program evaluate existing medical evidence in an unbiased way and set standards for clinical guidelines. Not only could such an initiative wipe out some uncertainty and disagreements over standards of care, it also could lower costs by eliminating ineffective care, the IOM panel said.

"If our recommendations are adopted and put into legislation, physicians will have better and more trustworthy information on what works in the practice of medicine," said panel vice chair Harold C. Sox, MD, who also is editor of the Annals of Internal Medicine.

With evidence-based medicine the goal, where to turn for reliable evidence looms large in health care. There are hundreds of clinical guidelines on some diseases and conditions, and often they conflict. There are 342 guidelines on cardiovascular diseases alone listed in the Agency for Healthcare Research and Quality's National Guideline Clearinghouse.

"We need a way to synthesize data about the effectiveness of health care products and services in a standardized, objective fashion that will be considered reliable and trustworthy by all decision-makers," panel chair Barbara J. McNeil, MD, PhD, head of Harvard Medical School's Dept. of Health Care Policy in Boston, said in a statement.

Doctors tend to sift through guidelines, zeroing in on those from organizations with good reputations. That's what Dr. Sox does. Still, "it's really tough even for someone who is pretty well-informed, like myself," he said.

Program would review medical data

Under the report's proposal, Congress would direct the Health and Human Services secretary to establish a program with responsibility for reviewing and releasing unbiased medical information. Members of the panel are optimistic about that happening.

"With a new administration eager to make its mark, we will be seeing some pretty well-refined bills being introduced in early 2009," Dr. Sox said.

Prior to the IOM report, Sen. Hillary Clinton (D, N.Y.) made expanding government funding for comparative research a part of her platform as a presidential candidate. America's Health Insurance Plans, a trade group representing insurers, also supports the idea.

Last year, Reps. Tom Allen (D, Maine) and Jo Ann Emerson (R, Mo.) sponsored a bill to give AHRQ $3 billion over five years to do comparative clinical effectiveness research. The bill is still in committee.

The American Medical Association opposed the Allen-Emerson bill because it did not include adequate physician representation on the advisory panel that would set study priorities. Key elements of the bill were inserted into the Children's Health and Medicare Protection Act that President Bush vetoed. The AMA has not publicly addressed the recommendations of the IOM report. In a separate move last year, the AMA adopted policy supporting funding of clinical- and cost-effectiveness studies as part of a strategy to address rising medical costs.

The IOM proposal is far from a panacea for the medical decision-making challenges facing physicians and patients, some experts warned.

"It could be that one intervention works a little better but costs a lot more, or that one thing works about the same as other therapies but has a much better safety profile," said Peter J. Neumann, ScD, director of the Center for the Evaluation of Value and Risk in Health at Tufts-New England Medical Center in Boston.

"Those are the realities of medicine. It's worth doing the studies to find out those things, but it won't address the hard questions in ways that some people believe they will. This could improve the knowledge base around practice, but may not save much money," Dr. Neumann said.