Implementing comparative effectiveness research: Lessons from the mammography screening controversy

(Garrison, NY) The firestorm that followed the November 2009 release of guidelines that would have reduced use of screening mammograms in women aged 40 to 49 highlights challenges for implementing the findings of comparative effectiveness research (CER), according to a new analysis. Meeting such challenges — which may become more common due to increased funding for CER — requires better communication to the public and stakeholders about evidence and its connection to health care quality and efficiency.

Michael K. Gusmano, a research scholar at The Hastings Center, and Bradford H. Gray, a senior fellow at the Urban Institute, write in Academy Health Reports that while “the idea of using evidence to improve health care policy decisions enjoys [broad] support,” its implementation “can encounter great resistance,” especially if it suggests that widely promoted technologies may not be worth the cost.

The authors cite the recent powerful objections to mammography screening recommendations released by the U.S. Preventive Services Task Force (USPSTF) that would reduce would eliminate the use of routine breast cancer screening mammograms in most women ages 40 to 49. These recommendations, based on a detailed review of research, concluded that the harms of the screening outweighed its benefits in this group.

While some groups, such as Breast Cancer Action, the National Women’s Health Network, and the National Breast Cancer Coalition, supported the recommendations, their voices were drowned by “an avalanche of negative reactions from professional associations (including the American Cancer Society), patient advocates, and elected officials from both political parties,” as well as Health and Human Services Secretary Kathleen Sebelius. Ultimately, the U.S. Senate agreed to an amendment that amounted to requiring the federal government to ignore the 2009 USPSTF recommendations in the newly enacted health reform legislation, and revert to the 2002 recommendations.

Examining the reasons behind the controversy, and what it portends for CER, the authors cite communications troubles in the way that the recommendations — which took constituents by surprise — were developed and released into a “highly charged political environment,” amidst broader societal concerns about government control of health care. They note that CER is “most likely to face challenges when findings call for some degree of `disinvestment’ — reducing use of an established technology,” as did the mammogram guidelines.

“Establishing broader support for the value of health services research, coupled with sustained efforts to communicate more effectively with the public, is crucial as the United States grapples with how best to improve the quality and efficiency of its health system,” Gusmano and Gray conclude.