Evidence-based medicine: Research leads to better clinical pathways

Process requires a systematic review of literature

The theory is simple: If physicians can evaluate published literature and review clinical trials to form a body of clinical recommendations for patient care, outcomes will improve.

The reality is a little more complicated: Doctors, particularly primary care physicians, frequently feel overwhelmed by the enormous body of research and rapidly changing recommendations for care.

The solution, some say, is evidence-based medicine (EBM).

In short, EBM involves taking the latest scientific data and incorporating it into practice, as opposed to traditional medical care which often fails to incorporate new research in an efficient way, "like the way your grandfather practiced medicine the same way for 40 years," says Jim Gaume, MD, a Nashville, TN, endocrinologist in practice with three other physicians. "Well, this isn’t your grandfather’s world anymore."

For example, under the old ways of practice, physicians monitored blood sugars of diabetics — sometimes. With EBM, HbA1c levels are monitored quarterly along with a long list of other factors.

EBM isn’t really new, but it’s an idea whose time has come in disease management as physicians struggle to find tools to help them "translate evidence into practice, improving outcomes, and saving in human terms and in terms of medical costs," says John McDonald, RN, MS, CPHG, administrator for the general medicine patient care center at Vanderbilt University Medical Center in Nashville, TN.

This is easier in an HMO setting with large resources to keep abreast of the latest developments, than in a rural practice, but it is possible in both, says Gaume.

Collaboration for better management

"EBM offers prompts and triggers and cues that are based on what we know makes a difference," Gaume says.

"Medicine now has more interest in prevention of complications of disease," adds McDonald.

Gaume, an enthusiastic supporter of EBM, found the resources to practice EBM through the Physicians Community Health Group (PCHG), a collaboration between St. Thomas Hospital in Nashville and 1,000 doctors in the surrounding area, 300 of them primary care physicians.

"All our members need is a fax machine and a flow sheet. They come to CME (continuing medical education) and they’re up and running," Gaume adds.

An organization like PCHG, Gaume says, can sift through the "foot-high stack of disease management strategies offered by a variety of journals, drug companies, associations, and the CDC that comes every month," analyze it and decide what should be incorporated into practice.

PCHG offers simple solutions, like providing coaches who spend time in doctors’ offices and make recommendations.

"Sometimes work flow in the office is a barrier to good care," Gaume says.

For example, nursing assistants in an office might be trained to have diabetic patients remove their shoes before the doctor enters the room. It’s such a simple thing, he says, but it reminds doctors to check patients’ feet each time.

Among the PCHG patient base are 5,000 diabetics spread over central Tennessee’s 12 counties.

For example, when the American Diabetes Association added the daily use of aspirin to its guidelines for care of diabetics last year, PCHG members were alerted and encouraged to "get more aggressive with patients."

PCHG devised a flow sheet for diabetics available on the desks in local hospitals.

"It creates a matrix in patient charts and ensures we don’t miss things we normally might forget," Gaume explains.

PCHG plans additional flow sheets for asthma and other diseases.

The form helps physicians track disease progress and complications early so they can "concentrate resources where they matter," Gaume says. "The recommendation for management intensity goes up as the patient’s risk level goes up."

Gaume is quick to point out that EBM is not formula medicine or case management by computer. He sees it as an integration of scientific data and individual treatment plans based on the patient’s needs.

Big resources

The resources are there at Kaiser-Permanente in California, where Allen Bredt, MD, FACP, a medical oncologist and assistant to the associate medical director for clinical services at the Southern California Permanente Medical Group in Panorama City, has been contributing to the giant HMO’s EBM assessments for the past five years.

"Medical practice has become so complex," Bredt says. "It’s beyond the human mind to read 100 articles and come up with a guideline on each disease."

Kaiser’s practitioners participate in designing evidence-based policies and internally generate guidelines for its physicians.

Bredt looks at EBM as "basing decisions on evidence showing effectiveness and benefit, so when there is evidence of benefit, then the physicians should do it."

The tricky part, Bredt says, is where there is insufficient evidence to sway practice one way or another. In those cases, Bredt says, "A physician should be conservative and use discretion."

Kaiser’s clinical guidelines are updated every two years.

He admits that over the 10 years Kaiser has been using EBM, it has sometimes been "difficult to implement the guidelines and compliance was frequently poor.

"With the help of Kaiser’s computer system, outcomes are now monitored," Bredt says, and "we make targets to help doctors and care teams constantly improve outcomes."

Kaiser does not formulate all of its guidelines from scratch and often relies on guidelines published by professional associations like the American Heart Association and the American College of Cardiologists which are "adopted and adapted to our system," Bredt says.

Kaiser in Southern California spends about $500,000 a year to develop guidelines, but "that’s not the entire cost by a long shot," Bredt says.

"Evidence-based medicine permeates everything we do," he says. "It’s really not possible to dissect it out from the entire range of disease management."

Can private practitioners do EBM?

For practitioners who are "out there" alone with no professional collaborators or HMO to turn to, EBM is still possible, Bredt says.

And no, he says, it is not necessary for a physician to burn the midnight oil reading stacks of journals to come up with the latest clinical data.

He recommends close contact with professional associations and private organizations that issue EBM guidelines, including:

    U.S. Preventive Service Task Force;
    Agency for Health Care Policy and Research;
    American Society of Clinical Oncologists;
    American College of Physicians;
    American College of Pediatrics;
    Hayes Group;
    Cochran Collaboration;
    ECRI (Emergency Care Research Institute).

"The health care industry is moving toward EBM because it is a bigger umbrella and includes preventive care," says McDonald. "Under the concept of EBM, once you’re healthy, it’ll keep you healthy and if you have a disease, it will get you as healthy as possible."

For more information, contact: Jim Gaume of PCHG at (615) 385-0546; John McDonald of Vanderbilt University Medical Center at (615) 343-7154; and Allen Bredt of Southern Permanente Medical Group at (626) 405-5766.