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NEWS: Janice Hopkins Tanne US Institute of Medicine recommends new body to assess what works in health care BMJ 2008; 336: 236 [Full text]

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The future of “what works in health care”

Kelsey C Collimore, Steven Taylor and Gordon J. G. Asmundson   (19 February 2008)

The future of “what works in health care” 19 February 2008
Kelsey C Collimore, Graduate Student University of Regina (S4S 0A2), Steven Taylor and Gordon J. G. Asmundson Send response to journal: Re: The future of “what works in health care”	To the Editor: BMJ recently reported [1] that the Institute of Medicine(IOM; part of the U.S. National Academy of Sciences) proposes that the U.S. needs “an independent program to evaluate which diagnostic, treatment, and prevention services work best for various patients and circumstances” ([2] p.236). The IOM further recommends that the most pragmatic approach would be to build upon the efforts of the IOM [2]. While there is room for improvement in the development of clinical practice guidelines, there are major concerns about allowing the IOM to have sole influence on policy regarding treatment, especially if the views of the IOM do not reflect the views of the clinical and research community. To illustrate the nature of this problem, earlier this year the IOM prepared a report on the treatment of posttraumatic stress disorder (PTSD) [3]. This report reached very different conclusions about “what works” for the treatment of PTSD compared to recent literature reviews, meta- analyses, and evidence-based clinical practice guidelines. According to the IOM’s report, there was sufficient evidence only to conclude that exposure therapies were efficacious, and inadequate evidence to determine the efficacy of other treatments, including medications widely used in the treatment of PTSD such as the selective serotonin reuptake inhibitors (SSRIs). The working group for this IOM report was largely composed of non -experts in the area of PTSD [see ref. 3]. In contrast, other, expert- based clinical practice guidelines [e.g., 4-7] generally agree that there are several empirically-supported treatments for PTSD, including SSRIs and psychotherapies aside from exposure therapy. Given the discrepancy between the IOM and other review panels about the efficacy of PTSD treatments, one wonders whether the IOM would produce discrepant findings with other expert panels about the treatment of other disorders. At this juncture it would seem premature and inappropriate to allow a single body such as the IOM to pass judgment on treatment efficacy. Clearly, it is important that the views of other groups, such as review panels composed of researchers and clinicians with expertise in a given disorder, be considered when shaping health care policy, especially if the views of the experts differ markedly from the views espoused by the IOM. References 1. Hopkins Tanne, J. (2008). US Institute of Medicine recommends new body to assess which treatments work in health care. British Medical Journal, 336, 236. 2. Institute of Medicine (IOM) Committee on Reviewing Evidence to Identify Highly Effective Clinical Services. (2008). J. Eden, B. Wheatley, B. McNeil, & H. Sox (Eds). Knowing what works in health care: A roadmap for the nation. Washington, DC: The National Academies Press. 3. Institute of Medicine (IOM). (2007). Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence. Washington, DC: The National Academies Press. 4. American Psychiatric Association (2004). Practice guidelines for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Washington, DC: Author. 5. Canadian Psychiatric Association (2006). Clinical practice guidelines: Management of anxiety disorders. The Canadian Journal of Psychiatry, 51, Suppl 2, 57S-64S. 6. Department of Veterans Affairs & Department of Defense. (2004). VAa/DoD clinical practice guideline for the management of post- traumatic stress. Washington, DC: The management of post-traumatic stress working group. 7. National Institute for Clinical Excellence (2005). Clinical Guideline 26: Post-traumatic stress disorder (PTSD): Tthe management of PTSD in adults and children in primary and secondary care. London, UK: National Institute for Clinical Excellence. Competing interests: None declared