Comparative effectiveness research in practice: the Drug Effectiveness Review Project experience.

AIM: Assess the effect of the Drug Effectiveness Review Project's comparative effectiveness research findings on prescribing behavior independently and in conjunction with a Medicaid preferred drug list. METHOD: We queried prescription drug claims and enrollment information from the 2001-2008 Medicaid Analytic eXtract and Medicaid Statistical Information System for 17 states using a Wilcoxon signed rank test design to evaluate the effects of the Drug Effectiveness Review Project's report release and preferred drug list implementation on ACE inhibitor prescribing behavior at a state level. The primary outcome of interest was the percentage of ACE inhibitor prescriptions that are defined as 'differentiated' based on the content of the Drug Effectiveness Research Program report. RESULTS: The use of differentiated ACE inhibitors increased significantly in states that participated in the Drug Effectiveness Research Program and subsequently implemented a preferred drug list (p < 0.05, one-tailed). However, there was no significant change in utilization in nonparticipating states or in states that participated but did not subsequently implement a preferred drug list. CONCLUSION: Although the publication of comparative effectiveness research findings may not directly influence practice, a preferred drug list can align utilization with clinical evidence. The states that participate in the Drug Effectiveness Review Project and use preferred drug lists have greater utilization of higher quality drugs, making the combination an effective strategy to translate comparative effectiveness research into practice.

Building academic health centers' capacity to shape and respond to comparative effectiveness research policy.

In recent years, the focus on comparative effectiveness research (CER), the funding available to support it, and the range of possible effects of CER policy on academic health centers (AHCs) have increased substantially. CER has implications for the research, education, and clinical care components of AHCs' missions. The current funding and policy environment have created specific opportunities for AHCs to shape and respond to CER policies across the four dimensions of the CER enterprise: research, human and scientific capital, data infrastructure, and translation and dissemination. Characteristics such as the degree of physician-hospital integration, the status of a health information technology infrastructure, and the presence of a well-developed cross-functional health services research capacity linked to the care delivery enterprise could help AHCs respond to these opportunities and influence future policies. AHCs are also essential to the development of methodologies and the training of the next cadre of researchers. Further, a focus on understanding what works in health care and increasing adoption of evidence-based practice must become embedded in the fabric of AHCs. Those AHCs most successful in responding to the CER challenge may leverage it as a point of differentiation in the marketplace for health care and lead transformational improvements in health.

Regulation of surface architecture by symbiotic bacteria mediates host colonization.

Microbes occupy countless ecological niches in nature. Sometimes these environments may be on or within another organism, as is the case in both microbial infections and symbiosis of mammals. Unlike pathogens that establish opportunistic infections, hundreds of human commensal bacterial species establish a lifelong cohabitation with their hosts. Although many virulence factors of infectious bacteria have been described, the molecular mechanisms used during beneficial host-symbiont colonization remain almost entirely unknown. The novel identification of multiple surface polysaccharides in the important human symbiont Bacteroides fragilis raised the critical question of how these molecules contribute to commensalism. To understand the function of the bacterial capsule during symbiotic colonization of mammals, we generated B. fragilis strains deleted in the global regulator of polysaccharide expression and isolated mutants with defects in capsule expression. Surprisingly, attempts to completely eliminate capsule production are not tolerated by the microorganism, which displays growth deficits and subsequent reversion to express capsular polysaccharides. We identify an alternative pathway by which B. fragilis is able to reestablish capsule production and modulate expression of surface structures. Most importantly, mutants expressing single, defined surface polysaccharides are defective for intestinal colonization compared with bacteria expressing a complete polysaccharide repertoire. Restoring the expression of multiple capsular polysaccharides rescues the inability of mutants to compete for commensalism. These findings suggest a model whereby display of multiple capsular polysaccharides provides essential functions for bacterial colonization during host-symbiont mutualism.