Last week, JAMA released a theme issue devoted to comparative effectiveness research (CER).
In contrast to traditional randomized clinical trials comparing an active intervention to a control condition (or placebo), CER compares existing interventions to each other to determine relative harms and benefits. CER research frequently includes patient preferences and patient-centered perspectives, and models have been developed to engage patients every step of the way. CER data are maturing and attracting enormous attention thanks to staggering sums of money provided through the American Recovery and Reinvestment Act in 2009 and the Patient Protection and Affordable Care Act of 2010. One of the CER studies published last week evaluated long-term outcomes after open vs. endovascular repair of an abdominal aortic aneurysm (JAMA. 2012;307:1621-28).
The study was a retrospective analysis of patients at least 65 years in the Medicare database who underwent repair of a nonruptured AAA. Open repair was conducted on 703 patients and endovascular repair was conducted on 3,826. After statistical adjustment for relevant potential confounders, a higher risk was observed for both all-cause mortality (hazard ratio [HR], 1.24 [95% CI, 1.05-1.47]; P=.01) and AAA-related mortality (HR, 4.37 [95% CI, 2.51-7.66]; P<.001) after open compared with endovascular repair. Hospital length of stay was 6.5 days longer and incisional repair was higher with open repair. One-year readmission, repeat AAA repair, and leg amputation did not differ between the two approaches.
This study has immediate implications for clinical counseling and referrals of patients who we were following and are now referring for large AAA’s. While the study’s retrospective analysis design may not be at the top of the evidence-based hierarchy, it’s a good example of how CER often yields the "best available evidence" for our clinical questions. Practicing clinicians will be well-served familiarizing ourselves with CER research if, for no other reason, than the following: funding agencies and health care insurers are paying attention. Cost-effective treatment approaches will likely receive preferential or exclusive reimbursement. This will undoubtedly have a stunning and transformative effect on the complexion of our practices.
Jon O. Ebbert, M.D., is professor of medicine and primary care clinician at the Mayo Clinic in Rochester, Minn. The opinions expressed are solely those of the author. He reports having no relevant conflicts of interest. To contact him, send an e-mail to ebbert.jon@mayo.edu.