Imaging and Comparative-effectiveness Research: A Conversation With William T. Thorwarth Jr, MD

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William T. Thorwarth JrComparative-effectiveness research has become the platform for several organizations, including the Institute for Clinical and Economic Review (ICER). Based at the Institute for Technology Assessment at Massachusetts General Hospital in Boston, ICER’s mission is to lead comparative-effectiveness–research innovation through methods that the organization says integrate considerations of clinical benefit and economic value through a unique collaboration with patients, clinicians, manufacturers, insurers, and other health-care stakeholders. William T. Thorwarth Jr, MD, of Catawba Radiological Associates (Hickory, North Carolina), is current chair of the CPT® editorial panel of the AMA, former president of the ACR®, and former chair of the ACR Economics Commission, was recently chosen to represent the ACR as a member of ICER’s advisory board. Thorwarth discussed ICER and the role of comparative-effectiveness research in the radiology sector with ImagingBiz. You sit on the ICER advisory board with a number of health-policy experts from various specialties, as well as with health-care stakeholders. Tell us a bit about the composition of the board and how members are chosen. Thorwarth: The advisory board is made up of 20 members who represent institutions that provide ICER with financial and operational support, as well as at-large representatives from key clinical, policy, and advocacy stakeholder organizations. It comprises a very balanced cadre of health-care providers, payors, purchasers, pharmaceutical companies, and vendors. The advisory board was created to provide strategic guidance to our organization and, as such, it must look at issues from every angle. This is something that cannot be accomplished without the involvement of representatives from all contingents, and members are chosen with a major focus on maintaining such a mix. Experience and qualifications come into play, but if, for example, a provider representative drops out, he or she will be replaced by a provider representative; if a payor representative leaves the group, another one—rather than a qualified individual from another category—will be asked to step in for him or her. You are the first radiologist to serve on the board. Why do you think the board sought a representative from this specialty? Thorwarth: ICER approached the ACR about adding a radiologist to the board. I believe much of this had to do with balance, as well as with the fact that radiology is edgy, just like many of the areas in which comparative-effectiveness research is being conducted. I think the fact that I currently chair the AMA’s CPT panel was one of the reasons that I, specifically, was asked to join the board. My work on the panel allows me to give ICER a good perspective on whether appraising a given treatment procedure is worthwhile. It is no secret that radiology reimbursement has been a target for reductions. Is there a role for comparative-effectiveness research in demonstrating the ability of radiology to reduce downstream costs? Thorwarth: Absolutely: Comparative-effectiveness research can confirm the appropriateness of modalities, as opposed to more expensive procedures—and, therefore, radiology’s role in cost reduction. Our recent comparative-effectiveness–research initiative on the use of coronary CT angiography (CCTA) for patients with suspected coronary-artery disease is a perfect example. While comparative-effectiveness research revealed only limited evidence to determine CCTA’s effectiveness in supporting clinical decision making or improving patient outcomes in the outpatient setting, it did show that the modality is comparable to other noninvasive diagnostic techniques in ruling out coronary-artery disease as the cause of chest pain, when used in the emergency department. It also confirmed the high diagnostic accuracy of CCTA compared with invasive coronary angiography, which is the standard of care. What are some of the projects that you expect to work on this year? Thorwarth: The big push for 2011 is treatment for low-back disorders and the proposed patient categories and treatments for comparison. It is a very important project, when one considers not only that low-back disorders are an exceedingly common complaint, with a lifetime prevalence ranging from 54% to 80%, but that chronic low-back pain might be seen in 25% to 60% of patients one year or more after an initial episode. The economic impact of low-back pain is incredibly substantial: It is the fifth most common reason for all physician visits in the United States, and it is responsible for direct medical costs that approach $30 billion annually. In addition, low-back pain is a major cause of lost productivity; it is estimated that 2% of the US work force is compensated for back pain or injury each year. Our appraisal will evaluate evidence on the comparative risks, benefits, and cost effectiveness of multiple management strategies for patients with chronic low-back pain. Pain in this category is of more than four weeks’ duration—without evidence of systemic disease or significant neurological findings. What is the ideal role of comparative-effectiveness research in the wake of health-care reform? Thorwarth: While innovation remains the name of the game, health-care decision makers are demanding increasingly comprehensive and solid evidence that new drugs, devices, procedures, and biologics bring true value to the table. Policymakers and those pushing for health-care reform continue to argue the point that simultaneously meeting the goals of innovation, cost control, and improved quality of care within the health-care system necessitates more explicit appraisal of the clinical effectiveness and comparative value of new interventions. Their requirements for existing interventions are identical. Conducting the necessary appraisals and, consequently, filling the evidence gap, as we call it, constitutes the ideal role for comparative-effectiveness research in the wake of health-care reform, now and going forward. Comparative-effectiveness research has been the target of outlandish accusations, with charges related to death panels being the most notorious. What should physicians and others in the health-care community be doing to depoliticize the subject? Thorwarth: The average physician is not going to become an activist. The best approach that can be taken is for medical societies to educate their constituents on the value and importance of comparative-effectiveness research in improving our health-care system, so as to put it in a better light for accusers. Julie Ritzer Ross is a contributing writer for