While the United States leads the world in many measures of health care innovation, it
has been suggested that it lags behind many developed nations in a variety of health
outcomes. It has also been stated that the United States continues to outspend all other
Organisation for Economic Co-operation and Development (OECD) countries by a wide
margin. Spending on health goods and services per person in the United States, in
2007, increased to $7,290 – almost 2½ times the average of all OECD countries. Rising
health care costs in the United States have been estimated to increase to 19.1% of gross
domestic product (GDP) or $4.4 trillion by 2018. The increases are illustrated in both
public and private sectors.
Higher health care costs in the United States are implied from the variations in the
medical care from area to area around the country, with almost 50% of medical care
being not evidence-based, and finally as much as 30% of spending reflecting medical
care of uncertain or questionable value. Thus, comparative effectiveness research (CER)
has been touted by supporters with high expectations to resolve most ill effects of health
care in the United States and provide high quality, less expensive, universal health care.
CER is defined as the generation and synthesis of evidence that compares the benefits and
harms of alternate methods to prevent, diagnose, treat, and monitor a clinical condition
or to improve the delivery of care. The efforts of CER in the United States date back to
the late 1970’s even though it was officially born with the Medicare Modernization Act
(MMA) and has been rejuvenated with the American Recovery and Reinvestment Act
(ARRA) of 2009 with an allocation of $1.1 billion.
CER has been the basis for health care decision-making in many other countries.
According to the International Network of Agencies for Health Technology Assessments
(INAHTA), many industrialized countries have bodies that are charged with health
technology assessments (HTAs) or comparative effectiveness studies. Of all the available
agencies, the National Institute for Health and Clinical Excellence (NICE) of the United
Kingdom is the most advanced, stable, and has provided significant evidence, though
based on rigid and proscriptive economic and clinical formulas.
While CER is making a rapid surge in the United States, supporters and opponents are
expressing their views. Part I of this comprehensive review will describe facts, fallacies,
and politics of CER with discussions to understand basic concepts of CER.
Key words: Comparative effectiveness research, evidence-based medicine, Institute
of Medicine, National Institute for Health and Clinical Excellence, interventional pain
management, interventional techniques, geographic variations, inappropriate care.
Varieties of Uncertainty in Health Care
