Practice of Evidence based medicine

5 Reasons the Practice of EvidenceBased Medicine Is a Hot Topic

John Haughom, MD , Senior Advisor, Health Catalyst

Posted in Health Catalyst University and Healthcare Transformation.

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Editor’s note: This mini lesson represents some of the content presented at Health Catalyst University’s Accelerated Practices (AP) Program. With the purpose of educating health professionals, the AP Program prepares healthcare teams to accelerate outcomes improvement. Faculty and guest experts of the program are recognized leaders in their respective fields of expertise. Below, Dr. Haughom, faculty member of Health Catalyst’s Accelerated Practices (AP) Program, shares insight about the growing importance of using evidence-based medicine—a topic he covers in his session on evidence-based medicine.

Imagine you’re a provider and you’ve just diagnosed a patient with stage II prostate cancer.

The patient is 84 and not showing any symptoms. Naturally, you want to choose the treatment that will provide your patient with the best outcome possible. How will you choose the right course of action? The practice of evidence-based medicine can help you and your patient determine the most appropriate medical treatment.

What Is Evidence-Based Medicine?

Evidence-based medicine includes three key components (Figure 1): research-based evidence, clinical expertise (i.e., the clinician’s accumulated experience, knowledge, and clinical skills), and the patient’s values and preferences.

Figure 1: The three components of evidence-based medicine.

Practicing evidence-based medicine is important in today’s healthcare environment because this model of care offers clinicians a way to achieve the Triple Aim’s objectives of improved quality, improved patient satisfaction, and reduced costs. To understand how, consider the prostate cancer example. With evidence-based medicine, a provider can assess the strength of the evidence as well as the risks and benefits of ordering diagnostic tests and treatments for each cancer patient. Such an approach, coupled with the provider’s clinical experience, enables the provider to better predict if a treatment will do more harm than good. It also helps the organization establish a systematic approach to caring for patients with specific conditions (e.g., prostate cancer, heart failure, diabetes). As reported in the article “The Importance and Impact of Evidence-Based Medicine,” using evidencebased medicine “help[s] physicians provide more rational care with better outcomes.”

Evidence-based medicine is not just about using evidence to design treatment plans; It also encourages a dialogue between patients and providers, so patients can share in the decision-making and make their values and preferences known. Together, patient and provider can determine an appropriate course of action—or no course of action if that’s on the joint decision. The benefit of this approach is that providers listen to patient concerns and take them into consideration to determine the appropriate treatment plan.

The Five Ways Evidence-Based Medicine Adds Value to Health Systems Evidence-based medicine helps health systems achieve “gains on all three [triple] aims at once: care, health, and cost,” as stated in the article “The Triple Aim: Care, Health, And Cost.” Therefore, it’s gaining momentum as a viable model of medical care. There are five ways it’s adding value to healthcare:

#1: Helps clinicians stay current on standardized, evidencebased protocols.

There’s an explosion of scientific knowledge being published, making it difficult for clinicians to stay current on medical best practices. In fact, for a primary care physician to stay up to date, they’d need to read 17 articles a day, 365 days a year. This is an impossible task, but evidence-based medicine offers clinicians a way to stay current with best practices using standardized, evidence-based protocols.

#2: Uses near real-time data to make care decisions.

Healthcare staff now has better access to data and more knowledge because of improved technology, such as electronic medical records (EMRs), decision support systems, built-in protocols, data warehouses, and sophisticated analytics. With this improved access to healthcare data, staff can use evidence-based medicine to provide better patient care based on near real-time data. As mentioned in the article “Evidence-Based Decision Making: Global Evidence, Local Decisions,” such “developments can greatly reduce the time necessary to fill gaps in the evidence base and reduce the uncertainty in the decisionmaking process.”

#3: Improves transparency, accountability, and value.

Payers, employers, and patients are all driving the need for the healthcare industry to show transparency, accountability, and value (e.g., high quality and safe care at the lowest possible cost). Practicing evidence-based healthcare can help the industry achieve these goals. According to the manual Evidence-Based Practice Manual: Research and Outcome Measures in Health and Human Services, “Evidence-based healthcare expresses commitment to improve the transparency of reasoning behind policies, increase accountability by justifying decisions on the basis of valid information that can stand up to scrutiny, gauge uncertainty by making explicit the strength of evidence supporting policy, and make policy decisions driven by the best outcomes for the healthcare dollar.”

#4: Improves quality of care.

Although the U.S. spends more money per person on healthcare than any other nation in the world, there is broad evidence that Americans often do not get the care they need. With evidence-based medicine, care improves because clinicians have access to previously untapped data and best practices vetted and agreed upon by peers.

#5: Improves outcomes.

The most important reason for the interest in evidence-based medicine is that it works.

There’s a lot of data that shows if health systems diligently use the best clinical evidence and expertise, and ensure treatments are consistent with patient values, they’ll realize better outcomes in every way. As demonstrated with 15 case studies in the publication Evidence Based Medicine Matters, the use of evidence-based medicine resulted in improvements ranging from quicker recovery times after surgical procedures to safer ways to deliver breech babies.

The Future of Evidence-Based Medicine

With the acceleration of the value-based payment movement that will continue in the years ahead, there is an increasing need for clinicians to have access to the best available evidence to make the best possible decisions to achieve the best possible outcomes.

Clinicians must practice evidence-based medicine.

This is an exciting time to be in healthcare because of the opportunities for improvement evidence-based medicine provides. Patients will feel confident they are getting the best care possible because treatments are based on the most current medical knowledge. Costs will also decrease when care improves. Concerns, such as avoidable readmissions, can be averted when evidence-based medicine is incorporated into daily healthcare operations.

The Five Steps to Transition to Evidence-Based Medicine

Moving entire organizations over to an evidence-based model of care presents a few challenges. First, adopting evidence-based medicine as a new standard of practice requires clinicians to change how they were taught to diagnose and treat patients (i.e., the traditional craftsman approach taught during residency or nursing school). Second, providers are already simply trying to keep up with their workloads to treat patients the

best they know how. Introducing a new model of care delivery—and learning how to effectively use it—takes time.

There are five steps busy clinicians can take to incorporate evidence-based medicine into their practices:

Step #1: Ask a clinical question to identify a key problem.

The first step to moving to an evidence-based model of care is to form teams of clinicians whose role is to ask questions to identify the critical few problems that need to be addressed. Examples of major problems most healthcare organizations need to address include improving throughput and reducing readmissions.

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It’s important to identify a high-priority problem that offers a significant return on investment. Once clinicians see large gains, they become engaged and excited about moving to an improved model of care. Women’s services, ischemic heart care, and surgical departments are examples of areas that typically offer opportunities for major improvements. Clinicians can ask several questions to help identify problems:

Why are we practicing this way? Clinicians naturally practice a certain way because that’s how they were taught. Yet with new medical discoveries coming out seemingly every day, what was once a best practice may not be anymore.

Are we adhering to best practices? It’s important to ask this question to determine if current practices are based on today’s most researched processes and practices that lead to the best possible outcomes.

Can we produce better outcomes with consistency? Care should always be provided based on the best available evidence. This reduces inconsistent outcomes, which improves quality and reduces costs.

Figure 2: The five steps of evidence-based medicine include the 5 A’s: ask, acquire, appraise, apply, and assess.

Step 2: Acquire the best evidence (medical knowledge) possible.

There are many different sources of evidence—from the knowledge clinicians gain from treating their patient populations to new research being discovered from highly organized randomized controlled trials (RCTs). But not all of this knowledge represents high-quality evidence that provides the best insight for patient care.

To help clinicians compare the quality between the various sources of evidence, David Sackett, MD, popularized the evidence-based medicine pyramid. Within in this pyramid, evidence in the top level is the strongest because it underwent a systematic review process and meta-analysis. Evidence in the lowest level is the weakest because it is primarily based on opinions and small sample sizes, which increases room for error.

Transitioning to an evidence-based model of care means encouraging clinicians to use the evidence found in the upper levels of the pyramid to see better outcomes with their patients. As stated in the abstract Evidence-based nursing practice: why is it important?, “Practices based on research findings are more likely to result in the desired patient outcomes across various settings and geographic locations.”

The following levels explain the knowledge types in each layer of the evidence-based medicine pyramid:

Level I

Evidence in Level I is considered the gold standard of medical knowledge because it comes from randomized controlled clinical trials (RCTs). As stated in the article What is a randomized controlled trial in medical research?, RCTs enable the results from a clinical trial to be “free from any bias that might otherwise be introduced by the people involved.”

Level II

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Evidence in Level II is not considered quite as reliable at evidence from Level I, but it is still better than Level III and Level IV. Level II evidence comes from three different sources: Controlled trials without randomization.

Cohort or case-control analytic studies.

Multiple time series studies (Because RCTs cover only between 10 percent and 40 percent of what clinicians do [depending on clinical domain], it is often true that the best evidence available to clinicians is their own observed aggregate data.)

Level III

Evidence in Level III is based on expert opinion from experts who’ve narrowed their focus as much as possible about a complex area. The downside is that sample sizes are usually too small and there aren’t any control groups. This leaves a large margin for error unless group statistical techniques are used to compile the opinions of many experts.

Level IV

“Evidence” in Level IV is based on personal experience. This is the least desirable source of evidence and lacks any statistical validity.

Figure 3: The four levels of evidence, ranked from most desirable sources at the top to least desirable sources at the bottom.

Step 3: Appraise the evidence (make sure it’s applicable to the population and the question asked).

There’s good evidence (e.g., from RCTs) and there’s bad evidence (e.g., from personal experience). Then there’s evidence that falls in the gray area—neither clearly defined as good nor bad. It can be difficult for clinicians to know whether to use evidence in the gray area.

To determine the evidence’s validity, a team of clinicians with several years of evidence appraisal experience should review the knowledge in question. The team can then determine if the evidence is valid (i.e., accurate) and applicable (i.e., useful for the situation or population being considered).

Figure 4: Determining the quality of evidence can be difficult when it’s not clearly good or bad.

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Clinicians should ask several questions when appraising the evidence:

Does the evidence improve decision making?

Does the evidence improve outcomes?

Does the evidence improve clinical quality or patient safety?

Does the evidence improve the care experience?

Does the evidence improve efficiency and lower costs?

Does the evidence improve our services?

Does the evidence improve access to healthcare services?

Does the evidence empower patients and families to improve their health?

Step 4: Apply the evidence to daily clinical practice.

If the evidence passes the appraisal step and adds value to the practice of medicine, then clinicians can incorporate the new knowledge into their daily clinical practice. It’s important to note that evidence-based medicine doesn’t replace a clinician’s expertise or judgment. Its purpose is to enhance their ability to make better care decisions based on the needs and preferences of the patient.

Since not all clinicians will understand the value of adopting a new standard of care, it’s essential to communicate the change and the benefit it adds to patient care. Clinicians will also appreciate if the addition of the new knowledge can be built into their current flow of work and not add extra work to their already busy schedules. Done well, this could improve workflow rather than detract from it.

Step 5: Assess your performance.

Last, assess any improvements to performance or outcomes the new evidence provides.

This can be accomplished by establishing a baseline and then measuring improvements.

This is an ongoing process—reassessing and re-measuring any gains or losses should be part of an ongoing cycle to ensure the best outcomes.

Evidence-Based Medicine: Key Takeaways

Three Key Components of Evidence-Based Medicine 1. Research-based evidence.

2. Clinical expertise (i.e., the clinician’s accumulated experience, knowledge, and clinical skills).

3. Patients’ values and preferences.

Five Ways Evidence-Based Medicine Adds Value to Health Systems

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5.

Helps clinicians stay current on standardized, evidence-based protocols.

Uses near real-time data to make care decisions.

Improves transparency, accountability, and value.

Improves quality of care.

Improves outcomes.

Five Steps to Transition to Evidence-Based Medicine 1.

2.

3.

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5.

Ask a clinical question.

Acquire the best evidence possible.

Appraise the evidence (make sure it’s applicable to the population and the question asked).

Apply the evidence.

Assess your performance.

Has your practice incorporated evidence-based medicine? If so, what has your experience been? If not, would you like to see this approach to care adopted at your organization?