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How Physicians Can Drive Comparative-effectiveness Research: Lessons from New Zealand

      The passage of the 2009 American Recovery and Reinvestment Act means the US federal government is committed to implementing a comparative-effectiveness research agenda. Since then, there have been wide-ranging debates around almost every element of comparative-effectiveness research.
      • Martin D.F.
      • Maguire M.G.
      • Fine S.L.
      Identifying and eliminating the roadblocks to comparative-effectiveness research.
      • Saha S.
      • Coffman D.D.
      • Smits A.K.
      Giving teeth to comparative-effectiveness research: the Oregon experience.
      • Wilensky G.
      The policies and politics of creating a comparative clinical effectiveness research center.
      An issue that has so far remained under-explored is the role of physicians. This role and how physicians might be involved in comparative-effectiveness research are important considerations. As front-line service providers, physicians have a considerable stake in how comparative-effectiveness research mechanisms are constructed, in leading collegial buy-in to associated processes, and in implementing recommendations through their clinical activities.
      A highly successful example of physician-led comparative-effectiveness research relevant to the US situation comes from New Zealand, home to 4.2 million people. Its mixed health care system is dominated by public hospitals with salaried doctors, but community-based primary care physicians almost all practice privately. They receive similar proportions of income from public sources as US primary care physicians. Most of New Zealand's primary care physicians belong to independent practitioner associations that are conceptually similar to US physician hospital organizations, albeit focused on primary care business.
      Southlink Health Inc., a 480-physician association, has been engaged in comparative-effectiveness research for at least 16 years. In 1997, to facilitate such work, Southlink created the Best Practice Advocacy Centre (BPAC). BPAC's core focus is on translating existing evidence, including guidelines created by other agencies such as the US Preventive Services Taskforce and the New Zealand Guidelines Group, then disseminating recommendations for “best practice” to primary care physicians. BPAC initially worked exclusively for Southlink members, but its activities were soon endorsed by other physician associations. Primarily this was because BPAC was a nongovernment entity, designed and run by privately practicing doctors, but also as its focus was guiding and supporting best practice. BPAC shareholders today include a university and 5 physician associations. It receives funding from various government sources to support work programs. This support means BPAC recommendations now go to every primary care physician, community pharmacist, and community practice nurse in New Zealand. Survey data show that almost 100% of recipients rank BPAC information highly in terms of trustworthiness, quality, and usefulness.
      • Dovey S.M.
      • Fraser T.J.
      • Tilyard M.W.
      • Ross S.J.
      • Baldwin K.E.
      • Kane D.
      'Really simple, summary, bang! That's what I need': clinical information needs of New Zealand general practitioners and the resources they use to meet them.
      This, in turn, means BPAC recommendations are widely adopted.
      BPAC's internal processes provide lessons for US physician organizations looking to establish comparative-effectiveness research mechanisms (Table). A Clinical Advisory Group first determines which issues are important and should be the subject of BPAC interventions, either for laboratory investigations or prescribing and treatment guidelines. This group includes physicians, nurses, pharmacists, biomedical scientists, and service provider management representatives. BPAC staff including the BPAC journal editor, physicians contracted to BPAC, and a pharmacist then design and put material together after reviewing available evidence around the issue involved. Completed intervention material is then sent to the Clinical Advisory Group for scrutiny and at least one medical expert in the field involved for their approval, before final approval by the BPAC Chief Executive Officer (a practicing primary care physician).
      TableBPAC Intervention Steps
      • Clinical Advisory Group selects issue for comparative-effectiveness research
      • Evidence for best practice intervention collated and practical recommendations formulated
      • Physicians and allied health professionals are typically then sent:
        This information also can be obtained from the bpac website: www.bpac.org.nz.
        •  Clinical practice recommendations via Best Practice and Best Tests journals
        •  Individualized laboratory and prescribing reports
        •  Case study with questionnaire
        •  Clinical audit package
      BPAC=Best Practice Advocacy Centre.
      low asterisk This information also can be obtained from the bpac website: www.bpac.org.nz.
      The following example is typical of the process for a BPAC intervention to promote changes in clinical practice. In 2005, BPAC developed evidence-based guidelines for appropriate laboratory testing to assess and measure inflammatory response. At the time, primary care physicians ordered approximately double the number of tests for erythrocyte sedimentation rate (ESR) as for C-reactive protein (CRP). In most situations CRP provides more valuable clinical information and should be the test of choice.
      • Husain T.M.
      • Kim D.H.
      C-reactive protein and erythrocyte sedimentation rate in orthopaedics.
      BPAC material on the issue was provided to an intervention group of 3372 physicians. There were several facets to the intervention process, which was delivered in 2 phases. Initially, targeted physicians were mailed a guideline booklet plus a case study from which a questionnaire, to be returned to BPAC, was derived. Six weeks later they received an individualized report of the number of ESR and CRP laboratory tests they had ordered over the previous year, along with the average number of ESR and CRP tests ordered by other physicians in their practice, region, and nationally. They also received questionnaire results (if they had participated in this) and a request form for a clinical audit package that includes clinical standards against which a physician can monitor their own performance and instructions for how to do so. Participation in the quiz and clinical audit was recognized by their professional re-accreditation program.
      Analyses show that there was a 60.0% decrease in the number of ESR tests among those in the intervention group from before the intervention to afterwards. Tests for CRP increased 63.1% in the same period. Tests per physician per year increased from 87.8 to 143.1 for CRP and decreased from 189.5 to 75.8 for ESR. The ratio of ESR to CRP testing was reduced from 2.2:1 to 0.5:1 and simultaneous testing of ESR and CRP decreased by 32.6%. Tests for CRP and ESR ordered by comparison physicians (who ordered tests from community laboratories but were not necessarily primary care physicians and did not receive BPACnz interventions) increased by 21.4% and decreased by 17.8%, respectively. After accounting for differences between intervention and comparison physicians before and after the intervention, the effect of the intervention was a 42% increase in CRP use and a 42% reduction in use of ESR for a saving of 21.1% in net expenditure compared with the 2 years before the intervention. Greater use of appropriate tests and reduced use of inappropriate ones implies an overall increase in care quality.
      Geographic variations in practice also reduced. The offices of intervention physicians were linked to New Zealand's 21 district health board regions for analysis. The ratio of CRP:ESR tests in the 2 years before the intervention ranged from 0.23 to 1.13 across these districts. After intervention the ratio ranged from 1.07 to 3.27; still considerable, but an improvement by at least 150% in all districts.
      BPAC has conducted a range of other interventions aiming to translate research evidence into practice with similarly positive results. Examples of previous campaigns include testing for thyroid function and for enteric pathogens in the investigation of infectious diseases; prescribing campaigns, especially around antibiotics and angiotensin-converting enzyme inhibitors; promoting appropriate care for diabetes; and the management of pain, depression, and cardiovascular disease in the elderly. Practice advice on these and the dozens of other campaigns since 1997 also is provided in BPAC's Best Practice and Best Tests journals, sent to all primary care physicians and allied providers.
      The BPAC case demonstrates the immense potential for physicians to lead the way in comparative-effectiveness research. It shows how physicians in private practice can organize to spearhead the agenda for comparative-effectiveness research as well as the processes for this. It shows that comparative-effectiveness research material can be held in high regard and become widely utilized by physicians when colleagues have been behind its development. Most importantly, the New Zealand experience has resulted in changing clinical practice among its primary care physicians. The American Recovery and Reinvestment Act now provides US physicians with an opportunity to get involved in driving comparative-effectiveness research.

      References

        • Martin D.F.
        • Maguire M.G.
        • Fine S.L.
        Identifying and eliminating the roadblocks to comparative-effectiveness research.
        N Engl J Med. 2010; 363: 105-107
        • Saha S.
        • Coffman D.D.
        • Smits A.K.
        Giving teeth to comparative-effectiveness research: the Oregon experience.
        N Engl J Med. 2010; 362: e18
        • Wilensky G.
        The policies and politics of creating a comparative clinical effectiveness research center.
        Health Aff (Millwood). 2009; 28: w719-w729
        • Dovey S.M.
        • Fraser T.J.
        • Tilyard M.W.
        • Ross S.J.
        • Baldwin K.E.
        • Kane D.
        'Really simple, summary, bang! That's what I need': clinical information needs of New Zealand general practitioners and the resources they use to meet them.
        N Z Fam Physician. 2006; 33: 18-24
        • Husain T.M.
        • Kim D.H.
        C-reactive protein and erythrocyte sedimentation rate in orthopaedics.
        Univ Pa Orthop J. 2002; 15: 13-16