The historical and moral imperatives of comparative effectiveness research

Commentary: How the debate about comparative effectiveness research should impact the future of clinical trials

Comparative effectiveness research represents the kind of research that arguably more directly affects clinical practice and policy. It includes observational studies, clinical trials, and systematic syntheses of existing literature. In this commentary, I argue for the ongoing and critical role of randomization in comparative effectiveness, noting the key differences between practical and explanatory trials.

Using lean techniques to define the platelet (PLT) transfusion process and cost-effectiveness to evaluate PLT dose transfusion strategies

BACKGROUND

Platelet (PLT) doses of 1.1 × 10(11), 2.2 × 10(11), and 4.4 × 10(11) /m(2) body surface area are equally effective in preventing bleeding. These different dose strategies involve different numbers of transfusions. We conducted a cost analysis of three separate PLT dose therapies.

STUDY DESIGN AND METHODS

A process map of preparation and administration of a PLT transfusion identified 46 steps (23 steps in the blood bank and 23 steps on the care unit). Time studies were conducted for these 46 steps. Supply costs and personnel costs were estimated based on time studies. We conducted a cost analysis of three separate treatment regimes involving 16 transfusions per patient for the low-dose, 12 transfusions for medium-dose, and eight transfusions for high-dose regimes.

RESULTS

The time and the cost of the transfusion process for the blood bank were 32.41 minutes and $21.93 per unit, and for the patient care unit, 58.36 minutes and $57.71 per unit. The total cost for a course of PLT therapy per patient ranged from $4503.77 to $7014.59 for three different PLT doses. For a simulated bone marrow transplantation unit with 259 patients annually, there would be approximately a $700,000 difference among the clinically equivalent low-, medium-, and high-dose treatment options.

CONCLUSIONS

The overall cost of transfusion therapy is more influenced by the cost of the product than the cost of providing the transfusion. Depending on the cost adjustment by the supplier for different doses of PLTs, a low-dose transfusion strategy can be less costly.

Building the evidence base for decision making in cancer genomic medicine using comparative effectiveness research

The clinical utility is uncertain for many cancer genomic applications. Comparative effectiveness research (CER) can provide evidence to clarify this uncertainty. The aim of this study was to identify approaches to help stakeholders make evidence-based decisions and to describe potential challenges and opportunities in using CER to produce evidence-based guidance. We identified general CER approaches for genomic applications through literature review, the authors' experiences, and lessons learned from a recent, seven-site CER initiative in cancer genomic medicine. Case studies illustrate the use of CER approaches. Evidence generation and synthesis approaches used in CER include comparative observational and randomized trials, patient-reported outcomes, decision modeling, and economic analysis. Significant challenges to conducting CER in cancer genomics include the rapid pace of innovation, lack of regulation, and variable definitions and evidence thresholds for clinical and personal utility. Opportunities to capitalize on CER methods in cancer genomics include improvements in the conduct of evidence synthesis, stakeholder engagement, increasing the number of comparative studies, and developing approaches to inform clinical guidelines and research prioritization. CER offers a variety of methodological approaches that can address stakeholders' needs and help ensure an effective translation of genomic discoveries.

The effect of blood storage duration on in-hospital mortality: a randomized controlled pilot feasibility trial

BACKGROUND

Whether the duration of storage of blood has an impact on patient outcomes remains controversial. The objective was to determine feasibility of a comparative effectiveness trial to evaluate duration of storage of blood before transfusion on in-hospital mortality.

STUDY DESIGN AND METHODS

A single-center randomized controlled trial was performed at an acute care hospital in Canada between June and December 2010, involving consecutive hospitalized patients needing blood transfusion. Patients (n=910) were randomly assigned in a 1:2 ratio to receive freshest available versus standard-issue (oldest available) blood. Four feasibility criteria were measured: proportion of eligible patients randomized, contrast in age of blood between treatment groups, real-time data acquisition, and trial impact on blood outdating. In-hospital mortality was also reported.

RESULTS

A total of 1075 of 1129 patients (95.2%) were eligible and 910 of 1075 (84.7%) were randomized: 309 received freshest available blood (1157 units), and 601 received standard-age blood (2369 units). Contrast in mean age of the oldest blood transfused between groups was 14.6 days: 12.0 (standard deviation [SD], 6.8) days in the fresh arm and 26.6 (SD, 7.8) days in the standard arm. Weekly recruitment and event reporting were achieved for all patients. The blood outdate rate was 0.10%. In-hospital mortality was 10.5%: 35 deaths (11.3%) in the fresh arm and 61 deaths (10.1%) in the standard arm (odds ratio, 1.13; 95% confidence interval [CI], 0.73, 1.76).

CONCLUSION

It is feasible to conduct a large comparative effectiveness trial comparing the effect of freshest available versus standard-issue blood on in-hospital mortality. The wide CI around the estimate for in-hospital mortality supports the need for a large trial.