Dissemination and Adoption of Comparative Effectiveness Research Findings When Findings Challenge Current Practices. Conclusions


Our analysis of the COURAGE trial and subsequent events suggests that the findings did not have an impact on clinical practice despite speculation that physicians might have pursued a more conservative approach to the management of stable CAD following the trial. The trial may have an important indirect effect on practice by encouraging the integration of appropriateness criteria for coronary revascularization into decision support tools that can be updated as new CER emerges. Efforts to use appropriateness criteria in quality improvement are nascent, and while they have yet to be used in an accountability or payment context, there is increasing interest among policymakers in pursuing them. How much these efforts will facilitate practice change remains unclear, but it seems likely that integration with cardiac registries and incorporation into decision support tools at the point of care could make a difference. Such initiatives will have greater effectiveness once reimbursement systems create demand for them. Changes in the organization of cardiology practices, driven in part by the movement toward ACO-based payment models, may be the single most important determinant of the future adoption of findings from COURAGE.

Several strategies may improve uptake for CER trials that share some of the characteristics of COURAGE. In the generation phase, the research focus should be on a decision point sufficiently upstream to impact decisionmaking meaningfully. A critical driver of the use of PCI is the initial decision to refer a patient to an interventionist, since this tends to create an expectation that angiography and PCI will follow. The COURAGE trial did not address the initial referral decision directly. Rather, it addressed a later decision point—after patients have already undergone angiography—at which the utility of decision support and patient-decisionmaking aids may be suboptimal. Current and proposed trials are focusing on decisions that occur prior to angiography, and these may have a greater impact on clinical practice. Other design problems to avoid include the potential for significant patient crossover and excessive time to complete studies. However, discussions with stakeholders suggest that these criticisms of the COURAGE trial design are likely to have played only a minor role in influencing practice patterns.

Interpretation and formalization can languish if study findings confirm current guidelines, even if they contradict current practice. Prior to COURAGE, practice guidelines were based on very weak evidence, promoting physicians’ inclination to disregard them, but since the COURAGE results reinforced the guidelines, there was less impetus to revise them. A CER result that necessitates a change in guidelines may have more impact. Similarly, payers and other stakeholders must have the ability to collect relevant appropriateness data, or they will have no incentive to develop reimbursement policies or quality measures.

Dissemination and implementation may be either advanced or hindered by several factors, but in this case, psychological aspects appear to be key. While registries may have influenced practice (by incorporating performance measures and appropriateness criteria into their design), their influence on appropriate use of elective PCI appears modest. Similarly, payer limits on upstream diagnostic procedures may have somewhat dampened demand for PCI, as might accountable-care reimbursement schemes in the future. Psychological factors, including concerns about harm and physician response to popular media coverage regarding PCI overuse, may modulate the tendency to intervene aggressively, but strong financial and psychological factors still incline both providers and patients to favor PCI. As one discussant put it, even without financial incentives, “interventionists love to intervene.” Patients may underestimate the effectiveness of optimal OMT, and patients may not be informed of, fully understand, or have access to available information on the benefits and risks of PCI. Patient and clinician decision aids may play a key role in helping to remedy this. However, to be maximally effective, such decision aids will have to be implemented in settings where financial incentives do not promote PCI and before patients have progressed along the referral pathway to the point where intervention becomes almost inevitable.

Key findings from the COURAGE case study are presented in Table 3.2.

Table 3.2

Key Findings from the COURAGE Case Study


Key Findings


•   There is a perception that the study design led to enrollment of low-risk patients, thereby limiting generalizability.

•   Focus on decisionmaking post-angiography is low-leverage; CER on upstream decisionmaking is seen as potentially more influential.

•   Patient crossover between treatments muddles the interpretation of findings.

•   The study was arguably underpowered, but it also took eight years to complete.


•   The multiple professional societies involved allowed different interpretations to persist.

•   A perception that study treatments were already outdated affected interpretation.


•   The findings confirmed existing guidelines (but not current practice), so no additional formalization occurred initially.

•   Health plans are able to collect only limited data on PCI indications, limiting their ability to monitor appropriateness or inform payment policy.


•   Criticisms of methodology in the peer-reviewed literature promoted popular media coverage.

•   Specialty-society guidelines, while developed rigorously, were not promoted energetically.

•   Registries may help disseminate findings through performance measurement and use of appropriateness criteria.


•   Reimbursement significantly favors PCI.

•   Referral to an interventionist can be interpreted as endorsement of the procedure.

•   Psychological factors in both patients and proceduralists drive a desire to fix all stenoses.

•   Payer limits on upstream diagnostic procedures, while controversial, may limit inappropriate use of PCI.

•   The move away from private practice in favor of affiliation with medical centers may alter financial incentives.

•   Potential harm from radiation exposure is an emerging issue that may dampen overuse.

•   Using patient decision aids covering treatments for angina may improve outcomes, but physicians need incentives to use them.

View full report


"rpt_RANDFinal.pdf" (pdf, 2.01Mb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®