{"id":30253,"date":"2012-11-18T22:24:48","date_gmt":"2012-11-19T03:24:48","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=30253"},"modified":"2012-11-18T23:19:46","modified_gmt":"2012-11-19T04:19:46","slug":"cost-accounting","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2012\/11\/18\/cost-accounting\/","title":{"rendered":"cost accounting…"},"content":{"rendered":"
I started medical school naively thinking of medicine and science as a somewhat linear march towards the truth, and woke up this morning thinking about fads in medicine<\/font><\/em><\/strong>, how they come and go much as in popular culture, and how many I’ve seen in the intervening half century. Last week, I was writing about Tom Insel’s NIMH Director’s Blog<\/font><\/strong> [the monocle…<\/a>], and I said:<\/div>\n
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So Insel’s NIMH has been a directed research agency, <\/font> jumping on the Translational Medicine ideas of the NIH – research focused on a speedy move to clinical application.<\/font> And it was more focused than that. There were any number of programs that announced topics of interest. My fantasy is that instead of sitting under an apple tree waiting for an inspiring bump on the head, researchers spend their time surfing through the NIMH web-site looking for what’s getting funded this cycle. Besides directed research, there was much ado about partnering with industry. And waves of Clinical Drug Trials – STAR*D, CO-MED, CATIE, TADS, TORDIA, etc. Rather than a funding source for creative scientists, NIMH has been pointing the way. And Insel’s NIMH has been fad-driven. Something that fits comes along, and he’s talking about it in his next blog. Pretty soon, it’s a new direction, a new program.<\/font><\/strong><\/sup><\/div>\n<\/blockquote>\n
Then today, I got a link to Dr. Insel’s most recent posting:<\/div>\n
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From Practice to Research<\/a>
NIMH Director’s Blog<\/font><\/strong>
By Thomas Insel
November 15, 2012<\/div>\n

…Recently, there has been a lot of hand wringing about the low efficiency of clinical trials, especially in mental health. They can be slow and expensive, and may not even produce actionable findings. Even when successful, there is a distressing delay in moving an important research finding from the research clinic into practice. In fact, we usually hear that there is a 17-year lag from research to practice. That is not always the case. The polio vaccine was implemented within days of the first report of success, and new AIDS medicines have been disseminated quickly. But for mental disorders and other chronic diseases like hypertension, there does seem to be a persistent gap between what we know from research and what we do in practice. At a meeting last week at NIMH, I heard how one group is working to close this gap. Greg Simon and his colleagues in the Mental Health Research Network [MHRN]<\/a> presented a new approach – we need to stop thinking about moving research to practice and start thinking about moving practice to research. That’s what MHRN does. MHRN is a network of 11 research organizations affiliated with non-profit health care systems serving 12 million patients. It is the largest research network for people with mental disorders in the nation. The idea is simple: understand what works in the real world of practice by using scientific methods, like randomization and statistical comparisons, to create a learning health care system. By linking health information databases and creating an efficient process for assessing outcomes, MHRN is working to transform the world of health care practice into a laboratory for research…<\/font><\/strong><\/sup><\/p>\n

Recently, the NIH Common Fund launched a broad version of this approach through its Healthcare Systems Collaboratory<\/a> project with practical trials on hypertension, dialysis, cancer, and suicide prevention. This project is catching the interest of large providers and payers who need answers about what works in the real world. There is a well-described "voltage drop," or decrease in efficacy, when we move treatments from the research setting to real world practice. But efforts like MHRN and the Collaboratory, which are bringing real- world practice to research, should help to reduce this problem. These large research-based practice settings can also serve as a dashboard for monitoring the changing needs of the population or the effects of changes in health policy.<\/strong><\/sup> For mental health, as we face an historic confluence of insurance parity and health care reform, the questions facing patients and providers are urgent. How should we deal with complex, comorbid health conditions? How can we reduce early mortality? How can we ensure fidelity of the best psychosocial treatments? What is the best strategy to personalize care? These are all pressing questions that can be answered rigorously in large practice networks with a solid infrastructure for conducting research…<\/font><\/strong><\/sup><\/div>\n<\/blockquote>\n
So I thought, here we go again – another technology, this time using electronic medical records in HMOs to do research on unsuspecting Plan Members. I thought of the warnings of InformaticsMD<\/a> on Healthcare Renewal<\/a>, about electronic medical records, the Quintiles<\/font><\/strong> scheme<\/a> to mine their free Internet service, <\/span><\/span>MediGuard<\/a>, to do clinical  trials on the Internet, and of the implication in recent books [eg  Pharmageddon<\/font><\/strong><\/u><\/a>] that rather than using clinical trials to inform medical practice, we were modelling medical practice to fit the clinical trial motif. So I read through Insel’s blog and started to move on, but then I clicked the Mental Health Research Network [MHRN]<\/a> <\/strong>link, almost by habit:<\/div>\n
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MHRN is based in the HMO Research Network<\/a>, a consortium of 19 public-domain research centers based in not-for-profit health care systems… MHRN centers have a greater chance of efficiently answering questions that involve real-world patients and providers through joining forces and combining resources. Initial funding for the MHRN is through a 3-year cooperative agreement with the National Institute of Mental Health [U19 MH092201 “Mental Health Research Network: A Population-Based Approach to Transform Research” with total costs of $8,999,198] and through a supplement from NIMH to the existing Cancer Research Network funded by the National Cancer Institute [with total costs of $1,499,873]. This initial funding cycle supports development of a core infrastructure for collaborative research as well as four developmental research projects to test and leverage that infrastructure in specific clinical areas.<\/strong><\/sup><\/div>\n<\/blockquote>\n
$10 M? four developmental research projects?<\/em> What developmental research projects<\/a>?<\/div>\n