Further research on each of the phases of translation and the interactions of stakeholders may help to optimize the CER research portfolio and its translation into effective clinical practice. Our case studies were retrospective and limited in number, so our conclusions are necessarily preliminary. Prospective evaluation of the effectiveness of CER results in changing clinical practice could help to refine the strategies used to interpret, formalize, disseminate, and implement CER-based clinical practices. The potential research and evaluation agenda is vast, and outlining it in detail is beyond the scope of this report. However, our results suggest a set of potentially high-priority areas for investment.
1. Support of research to identify the gaps in clinical decisionmaking that are the highest-priority topics for end users of CER. Understanding the needs of potential end users of CER could be an important goal of a research portfolio. Information about the gaps in clinical decisionmaking that could be topics of CER could be gathered in a variety of ways. Stakeholders involved in governance could be one source of input, but they may not provide a complete picture of the high-leverage opportunities for CER.
Other approaches include studying the potential and actual responses of key stakeholders (such as professionals, payers, and the public) to plausible CER study outcomes to obtain data on the factors that interact to yield successful changes in practice. Using these factors to model and anticipate the effects of stakeholder responses to CER results in each of the phases of CER translation could help to identify topics that are feasible targets for change. In addition, research on end-user needs could foster the selection of approaches for dissemination of CER results tailored to the expectations of these stakeholders.
Encouraging the design of CER studies that examine key clinical diagnostic decision points that are upstream from the use of drugs or procedures may also increase the relevance of CER to payers, professionals, and the public.
2. Promoting integration of the CER registry with clinical registries to support evaluation of the impact of CER studies and the factors associated with successful translation. Prospective evaluation of the impact of CER can be strengthened by reliable estimates of current clinical-practice patterns. Our results suggest that practice patterns, particularly rates of use of alternative treatments for specific indications and variations in those rates, may be incompletely understood. Without credible baseline estimates, it may be difficult to study the changes in clinical practice that follow publication of CER results.
Furthermore, clinical-decision algorithms often include contingencies such that the downstream treatments are promoted or impeded by decisions that occur earlier in the diagnostic algorithms that clinicians use. CER results pertinent to these downstream treatment choices can be helpful but may require accompanying research about diagnostic choices that occur upstream. Our COURAGE case study suggested that future CER focusing on the role of stress-testing within clinical decision algorithms may help to better tailor the use of downstream treatments such as angiography and PCI. Clinical registries that can provide longitudinal data on patients may enable more-complex studies and increase the relevance of results for end users.
Finally, the linking of the CER registry with clinical registries that enable the study of impact could assist policymakers in refining knowledge of the factors associated with successful translation of CER results from different types of CER studies.
3. Support of projects that develop unbiased and efficient methods for formalization of CER results. At present, guidelines, performance measures, and clinical decision support tools are the primary approaches to formalizing CER evidence into clinical-practice recommendations and tools that can be used to disseminate CER results and CER-based practices. Methods for developing and refining these tools and assuring that they are unbiased are still a work in progress. Support for research and demonstration projects that develop and study new methods for formalization could lead to more effective, efficient, and unbiased tools.
Research on formalization might focus on methods for assuring transparency through the use of formal panel protocols, criteria development, explicit rating algorithms, and statistical methods for weighting the priority of evidence and the tools that are produced. Development of new HIT applications that could accelerate the use of these methods and reduce the cost of producing such tools could be a key priority.
4. Support of projects that enhance the utility of CER results by demonstrating and evaluating models for the use of decision aids by clinicians and patients. Effective clinical practice is built on effective clinical decisionmaking. Shared decisionmaking is inherently difficult to implement because of incomplete information and information asymmetries between professionals and patients. One of the major contributions of CER is the provision of information professionals and patients can use to arrive at optimal diagnostic and treatment decisions. But financial incentives, marketing, and prior beliefs complicate the task of introducing CER evidence.
Our results suggest that designing more-effective decision aids, training professionals to use them, and strategies for embedding them in routine practice have all proven challenging. Research and evaluation projects that lead to better decision aids and more effective use of them could increase the demand for and impact of CER.
5. Support of research into the ways in which CER evidence is used by integrated delivery systems. While a small number of experts from integrated delivery systems participated in our discussions, a more systematic assessment of the ways in which these organizations use CER evidence merits further study. Because integrated systems routinely evaluate evidence with the explicit goal of developing clinical-guidance tools, they may have unique perspectives on which CER topics are likely to have the greatest impact on clinical practice. In addition, lessons learned by integrated systems involving the translation of CER evidence into practice could provide insight into the development of policies that are useful outside of these systems. For example, we learned that integrated systems are more likely to have their own guideline-development processes, sophisticated HIT systems, and greater levels of patient trust—all of which are conducive to CER translation. Future studies might engage these organizations to elicit best practices in CER translation and evaluate which strategies may be transferrable to nonintegrated delivery settings.