Evidence-Based Medicine in Practice: Professions, Patients, and the Pay-Off

1. Evidence-Based Medicine in Practice: Professions, Patients, and the Pay-Off Stefan Timmermans, UCLA

2. Evidence-Based Medicine • “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” David Sackett • Against “eminence-based medicine” • Various forms: • Meta-analysis • Critical self-evaluation • Clinical practice guidelines

3. Clinical practice guidelines • IoM definition: “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.” • Process: • Experts formulate clinical question • Review evidence • Rank evidence • Recommendation

4. Hypertensive disorder in pregnancy • BP should be measured with the woman in the sitting position with the arm at the level of the heart. (II-2A) • An appropriately sized cuff (i.e., length of 1.5 times the circumference of the arm) should be used. (II-2A) • Korotkoff phase V should be used to designate diastolic BP. (I-A)If BP is consistently higher in one arm, the arm with the higher values should be used for all BP measurements. (III-B) • BP can be measured using a mercury sphygmomanometer, calibrated aneroid device, or an automated BP device that has been validated for use in preeclampsia. (II-2A) • Automated BP machines may underestimate BP in women with preeclampsia, and comparison of readings using mercury sphygmomanometry or an aneroid device is recommended. (II-2A)Ambulatory BP monitoring (by 24-hour or home measurement) may be useful to detect isolated office (white coat) hypertension. (II-2B) • Patients should be instructed on proper BP measurement technique if they are to perform home BP monitoring. (III-B)

5. Some problems in creating guidelines • Insufficient evidence • Skewed evidence: recent drugs vs. rest • Evidence follows the money • Population data >< Individualized interventions • Too many guidelines: 516 on hypertension

6. Proliferation of Guidelines • 2,000 to 4,000 annually • Worldwide • US: National Guideline Clearinghouse • UK: Cochrane collaborative and NICE • Spread through other occupations

7. Controversy: • Survey of Physicians: 70% CPG improve quality of care, 43% increase health care costs, 68% discipline physicians, and 34% medical practice less satisfying (Tunis et al. 1994). • Critics: dehumanization of care • Proponents: rationalize medicine

8. Sociological interest in EBM-CPG • Change in power of medical professions: • 60s: golden age of doctoring • 70s-present: • Corporations • Government reforms • Consumerism • Do CPG exemplify decline or strength of professional power?

9. Three questions: • Why do professions develop clinical practice guidelines? • What is the effect of clinical practice guidelines on medical care? • Do patients benefit from EBM?

10. 1. Why professional interest in CPG? • Three major problems in US health care: • Rising costs: 17.6% of GDP • Access to health care: 45 million uninsured • Quality: Practice variation

11. Source: Wennberg 1999 Source: Wennberg 1999

12. Problem of Practice Variation • Not patient preferences or disease incidence • Instead provider practice styles • Under use, overuse, and misuse of services • Medical errors • What is scientific in medicine? What is the basis for medical costs?

13. CPG for professional groups • Professional service of organizations to their members • Justification for clinical autonomy: commitment to high standards of care • Confirm expertise-jurisdiction

14. 2. Effect of CPG on clinical care? • Implementation gap • Hypertension guidelines: • Little awareness of guidelines • If known, low behavioral change: 54.9% • Modest effect • Explanation • Ignore patient preferences-meanings • Ignore practitioner skills • Passive education • Herding cats

16. 3. Do patients benefit from CPG and EBM? • Strongest finding: lots of interventions with little evidence behind it • 44% likely beneficial • 49% neither harm or benefit • 7% likely harm • 96% required more research (El Dib 2007) • But does EBM improve population health? • Only a handful of studies • Variation of effects but mostly positive

17. Strength or decline of profession? • Professions: address practice variation • Political insurance • Avoid more draconian reforms • Self-regulation • Russia, nursing, allied professions • Still, herding cats: work-arounds • Imperfect professional tools

18. Is EBM doomed? • Practice variation remains a problem • Passive education does not work • Financial incentives also mixed track record • Still, guidelines may be successful as part of comprehensive reform.

19. An example • Shift from nebulizers to inhalers-spacers : 95% success rate • Multidisciplinary team of nurses-providers • Review literature-create guideline • Input at workshops, explain rationale • Media campaign • Weekly chart reviews • No silver bullets: guidelines alone are insufficient to change behavior but they can work as part of comprehensive reform

20. Thank you !