The Ali & Science of Evidence-Based Care RESEARCH BY MATTHEW WEINSTOCK

T he shift to a value-driven delivery model hinges on a

key element: patients’ achieving the best possible out-

comes. The linchpin to that is ensuring that clinicians

regularly follovi best practices and adhere to evidence-

based protocols.

“If this [transformation] is about value and value equals qual-

ity divided by cost, then it makes sense that you look at the evi-

dence,” says Joseph Pepe, M.D., CEO of Catholic Medical Center,

Manchester, N.H.

Pepe, who served as CMC’s chief medical officer for 12 years

before moving into the chief executive role in 2012, acknowledges

that one of the biggest stumbling blocks to instituting evidence-

based practice more broadly is the fear that it is “cookbook medi-

cine.” That’s a passé notion, he says. Evidence-based care is not

only about following results from the most recent clinical studies,

but blending that with a patient’s values and desires, as well as

relying on a physician’s judgment.

“Physicians have gotten a bad rap,” says Jean Slutsky, direc-

tor of the Center for Outcomes and Evidence at the Agency for

Healthcare Research and Quality, when talking about the percep-

tion that doctors routinely reject the move toward evidence-based

care. “Physicians are lifelong learners. The very nature of what

they do is about learning.”

A 2008 AHRQ handbook on implementing evidence-based

care supports the notion that this is not a completely rigid process.

It defines evidence-based care as “the use of current best evidence

I ABOUTTHISSERIES I H&HN created this exclusive Fiscal Fitness series with the support of the VHA last year to highlight strategies

hospitals are using to improve quality of care while increasing efficiencies and reining in expenses. In 2013,

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in conjunction with clinical expertise and patient values to guide health

care decisions.” That definition first was popularized by David Sackett,

a Canadian doctor, in a 1996 British Medical Journal editorial. “Good

doctors use both individual clinical expertise and the best available

external evidence, and neither alone is enough,” he argued.

For example, Slutsky says, the evidence may suggest that a patient

be put on a certain medication. Best practice may be to prescribe one

pill a day for 10 days. In a shared-decision model, which is also a critical

part of the process, the physician and patient would discuss the best

option available — perhaps it is using a different drug on the formulary

that’s more affordable but requires the patient to take the medication

three times a day.

Another factor to consider: “What level of risk for side effects is

the patient wilHng to assume?” Slutsky asks.

The AHRQ advises that when developing a process to implement

evidence-based practices, hospitals view things from the clinician’s per-

spective. In doing so, it recommends selecting areas for improvement,

“rather than asking what findings ought to be disseminated.”

That’s the approach Kaiser Permanente follows.

“We spend a lot of time trying to figure out what clinical ques-

tion we want to answer,” says Scott Young, M.D., associate executive

director, clinical care and irmovation, at the Permanente Foundation.

Once an area is identified. Kaiser Permanente has a robust pro-

cess for reviewing clinical guidelines and disseminating new protocols

throughout the health system. Scott says topics come up for review

by a variety of different means [See case study.]. Perhaps the most

important element of the process, he says, is physician buy-in. Because

protocols are put through a rigorous review, clinicians have confidence

that following them is in the best interest of the patient. ‘ •

Having physician champions who can effectively advocate for the

use of evidence-based care improves the likelihood that protocols will

be adopted widely. The AHRQ report highlights two kinds of backers:

• Opinion leaders: These people are “trusted to evaluate new infor-

mation in the context of group norms.” They are expert at explaining

why research findings need to be implemented into regular practice.

• Change champions: These clinicians are “passionate about inno-

vation, committed to improving quality of care, and have a positive

working relationship with other health care professionals. They circulate

information, encourage peers to adopt the innovation, arrange demon-

strations and orient staff to the innovation.”

As with everything else in health care, senior leadership support

is also instiimiental. The AHRQ report states that senior leaders need to

incorporate evidence-based care into the organization’s overall mission,

vision and strategic plan; it needs to be a fundamental staff expectation.

With payment models moving toward an approach that rewards

good outcomes and penalizes bad ones, hospitals will be assuming much

more financial risk for patient care. That, experts say, demands greater

attention to evidence-based care.

“What choice do we have?” Scott asks. “We have to base care on

evidence going forward. When we start talking about value, we need to

look at what our patients want and need. Wliat’s the best evidence and

how can we bring that to bear?” •

.0 . –

K N O W L E D G E T R A N S F E R : A FRAMEWORK FOR AHRQ PATIENT SAFETY PORTFOLIO AND GRANTEES

Knowledge creation and distribution

Creation of new knowledge,

practices and products

Distillation of key knowledge, practices or

products

Diffusion and dissemination

Creation of dissemination partnerships/

knowledge transfer teams

Adoption, implementation and institutionalization

Development of

interventions

Adoption and

implementation

Confirmation, adaptation and internal institution-

. alization .

External institutional-

ization/ routinization

Mass diffusion of key knowledge

and products

Targeted dissemination/

persuasion

Source: Evidence Based Paractice Implementation, AHRQ,i9oo

CASE STUDY

Alexîan Brothers HOFFMAN ESTATES, ILL. Jason Washbum wanted to know how effective treatments were

at Alexian Brothers Behavioral Health Hospital. “We didn’t nec-

essarily know if a patient got better,” says Washburn, director

of the hospital’s Center for Evidence-Based Practice. “We knew

they were at a level where they could be safely discharged and

wouldn’t be a harm to themselves or someone else.” The only

real metric the hospital had was readmissions.

In 2006, the hospital started trying to conceptualize mental

health care around evidence-based practices. It created question-

naires to conduct patient assessments. The challenge was coming

up with relatively short forms that patients could complete quickly

and that would produce meaningful results.

While the surveys have improved the hospital’s ability to

assess a patient’s pre- and post-discharge condition, there’s still

a gap in longer-term follow-up.

In some areas, the hospital is on the cutting edge of imple-

menting evidence-based protocols. Clinicians are using virtual

reality to treat Millennials with chemical dependency. “We want

to see what wül trigger that behavior,” Washbum says. “We can

create those environments in virtual reality.” •

Kaiser Permanente OAKLAND. CALIF. “Kaiser Permanente is a care delivery system that believes in

evidence,” says Scott Young, M.D., associate executive director

for clinical care and irmovation at the Permanente Federation,

which represents Kaiser’s medical groups. The system has a

dynamic process for instituting evidence-based protocols and get-

ting them out to its 16,000 physicians. A national panel reviews

new evidence, but protocols must be approved by the eight medi-

cal groups before becoming the standard of practice.

For major conditions such as diabetes and hypertension,

the panel reviews clinical guidelines top to bottom every two

years. Other protocols “bubble up on their own,” some are

brought forward by clinical leaders.and in some cases, the

health system looks at the “burden and suffering” of a patient

population.Kaiser’s regions can develop their own guidelines or

modify national guidelines based on patient demographic. Many

of the system’s evidence-based order sets have been built into

the electronic health record. Clinicians also have anytime digital

access to a clinical library that contains an enormous amount of

literature and aids. •

In a 2010 report, researchers at Duke University Medical Center Library and the University of North Carolina at Chapel Hill Health Sciences Library outlined six key steps in implementing evidence-based practice.

ASSESS Start with the patient. A clinical problem or question arises from patient care.

ASK Construct a well-built clinical question derived from the case.

ACQUIRE Select the appropriate resources and conduct a search.

APPRAISE Appraise the evidence for its validity and applicability.

APPLY Return to the patient and inte- grate that evidence with clinical exper- tise, patient preferences and appty it to practice.

SELF-EVALUATION ‘ Evaluate your performance with this patient.

Source: “Introduction to Evidence-Based Practice,” Uni- versity of North Carolina at Chapel Hill Health Sciences Library, July 2010

GETTING IN STEP According the AHRQ, there are three major steps for adopting

evidence-based care: knowledge-cre- ation, dissemination, implementation.

KNOWLEDGE CREATION AND DISTILLATION: 1. Research results in new findings that

can be put into action. 2. Distillation should consider such

things as how the findings will trans- fer to real-world settings.

DIFFUSION AND DISSEMINATION: 1. Create partnerships to disseminate

information. 2. Mass diffusion of key products 3. Target dissemination at specific

groups

ADOPTION AND IMPLEMENTATION: 1. Develop interventions. 2. Adopt and implement. 3. Confirm adoption across the institu-

tion. k. External partners adopt practices.

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