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Going from CER to Patient-Centered Care: Implications of Heterogeneity

Going from CER to Patient-Centered Care: Implications of Heterogeneity. Trial: Is treatment A better than treatment B? Clinician : Is treatment A better than B for this specific patient? Health care system : Is treatment A better than B, and for whom, in which settings?.

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Going from CER to Patient-Centered Care: Implications of Heterogeneity

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  1. Going from CER to Patient-Centered Care: Implications of Heterogeneity Trial: Is treatment A better than treatment B? Clinician: Is treatment A better than B for this specific patient? Health care system: Is treatment A better than B, and for whom, in which settings?

  2. Heterogeneity and Policy • Policies seek to promote use of “best” treatment option. • “Best” treatment for population may not be same as that for individuals. • Most important when variation is: • Common • Leads to big enough differences to change decision making • Treatment choices can’t be adjusted

  3. Audience Response • Is CABG the best option for all patients with diabetes? • How might a health system encourage greater use of CABG in appropriate patients? • Would it be appropriate to discourage CABG in groups where PCI produces equivalent outcomes?

  4. Is CABG the “Best” Choice for Patients with Diabetes? • Need to consider harms and complications • Patient preferences for different outcomes • E.g. short-term risks of CABG • Variation due to quality of surgeon • Applicability of trial evidence

  5. Policies Used To Influence Use of “Best” Treatments • Guidelines • Audit and Feedback • Coverage decisions • Non-coverage • Conditional coverage • Tiered coverage • Quality Measurement • Incentives, Public reporting

  6. Distinguishing Important from Unimportant Heterogeneity • Does it change direction of NET benefit enough to alter decisions? • Is it common? • Is it predictable? • Can it be detected and treatment modified in response to variation in benefits or harms?

  7. Example: SSRIs for Depression • Comparable effectiveness of most agents in depression responsiveness but individual variation • Affect decisions: YES -- Variability in response and side effects • Common: YES • Predictable: NO • Can variable response be monitored? YES

  8. Dealing With Variation in SSRI as Response in Policy • Not possible to identify who will do better on a different agent • Cover only 1-2 SSRIs in formulary? • Recommend starting all patients with a specific SSRI as initial therapy?

  9. Conclusions • Heterogeneity is a real and important phenomenon in research and policy • Examination of pre-specified factors in individual trials, SRs and meta-analysis can detect HTE • Be cautious about post-hoc sub-groups • Policies need to accommodate HTE • But doesn’t mean that complete, unfettered clinician choice is best

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