November 02, 2017
How is evidence-based medicine (EBM) implemented by today's providers and payers? As we observed in a previous entry on the topic, EBM is a major step forward from older systems of medicine such as humorism and unproven (but once commonplace) procedures such as bloodletting.
It prioritizes scientific evidence such as randomized controlled trials (RCTs), while de-emphasizing less reliable testimonials, case studies and anecdotes. However, there are numerous hurdles to overcome in EBM implementation.
Common obstacles include keeping pace with rapid medical innovation, as well as finding sufficient usable evidence under circumstances in which conditions may be only vaguely defined by the patient (such as in family medicine) and, as such, challenging to diagnose and assign a course of treatment. Accordingly, RCT results are often paired with other sources of evidence when deciding how to treat specific patients.
While rooting medical practice in evidence is not controversial, many challenges arise when determining which evidence to use and how to apply it. The success of a given treatment often hinges on such choices, since they can determine which interventions are used, whether and how long a patient remains hospitalized, and which measures are necessary to comply with state and federal regulations.
Fortunately, many detailed frameworks exist, offering comprehensive direction on how to assess and apply evidence for a wide variety of tests, treatments and practices under the EBM umbrella. Given the high stakes for proper EBM implementation across the healthcare sector, such guidelines are critical in ensuring the delivery of safe, effective and affordable care.
Specifically, now that patient outcomes have become integral to the ongoing transition to value-based reimbursement (VBR) and care, EBM can be a powerful vehicle for reaching that destination:
The different EBM guidelines offer a roadmap toward VBR. They provide details for scaling the EBM approach – which entails identifying a problem, gathering evidence, evaluating it, applying it and assessing the final results – to a broad spectrum of conditions and cases.
Some of the commonly used EBM frameworks include MCG Health, UpToDate, ACOEM and Official Disability Guidelines. Collectively, they provide highly specific guidance on virtually all conditions providers and payers may encounter. Let's examine a few of them in more depth:
The U.S. Centers for Disease Control and Prevention has estimated that chronic diseases - including stroke, type 2 diabetes, arthritis and some mental health conditions - are among the costliest and most common ailments in the country. They affect half of U.S. adults, account for 7 of the top 10 causes of death and make up 86 percent of annual healthcare expenditures. Any EBM system must have a clear roadmap for their treatment. For example, the EBM guidelines from MCG Health help inform:
In addition to treatment, EBM recommendations can be used for diagnoses. For example, they have played a prominent role in the conversation about regulations governing truck drivers and their unique susceptibility to obstructive sleep apnea (OSA).
In August 2017, the U.S. Department of Transportation withdrew a rule designed to set OSA screening protocols for commercial drivers. An earlier survey of American College of Occupational and Environmental Medicine (ACOEM) members found that 92 percent felt that OSA screening was important for drivers, although many reported not following an established protocol.
ACOEM itself has published guidance for standardized OSA screening. These guidelines include a mix of statistical measurements (e.g., thresholds for body mass index and neck circumference that indicate risk factors) and observations of excessive daytime sleepiness, among other criteria.
EBM guidelines are constantly evolving as new RCTs and other studies are published. Consider the case of EBM practices in relation to angiography, which provide images of arteries, veins and heart chambers, often for purposes of diagnosing coronary heart disease.
There have been numerous studies in recent decades about the cost-effectiveness of angiographies for certain classes of patients, along with comparisons of different angiography methodologies including invasive and computed tomography angiography. Moreover, researchers have attempted to understand the optimal timing for angiography in patients with non-ST-elevated acute coronary syndromes (NSTEACS); an article on this subject appeared in an August 2017 UpToDate news feed.
While there is no definitive evidence to date on replicable mortality reductions from relatively early angiography interventions, this type of ongoing review of evidence - whether for NSTEACs or something else - is typical in EBM. The guidelines are not set in stone and they evolve alongside medical science.
This continual improvement of EBM standards makes them reliable resources for both providers and payers, who can in turn provide superior care to patients. Benefits of EBM are wide-ranging and they include:
Prices in healthcare are much less transparent than in other industries. There is no equivalent of looking around for the gasoline station with the lowest price. Such opacity has consequences: For example, a study published in JAMA Internal Medicine found that mammography prices varied by a factor of five across California.
While pioneering transparency initiatives in Oregon and elsewhere have helped raise this issue, patients still often overspend since they wrongly assume a relationship between cost and quality. With EBM, outcomes can be better aligned with costs as ineffective (and expensive) treatments are discarded.
An assessment of medical literature once estimated that practitioners would need to read 19 journal articles per day, just to keep up with current methodologies. This is a challenge even for the most dedicated practitioners.
EBM helps remove this burden by creating a widely shared base of knowledge for practice. Moreover, this information is more accessible than ever before thanks to channels such as online journals, electronic databases, and cloud-based software.
Virtually all hospitals now have an electronic health records system in place. Meanwhile, data warehouses have become more important in helping with aggregation of health, financial and clinical information from disparate sources.
Analytics was a top-three priority for two-thirds of healthcare providers surveyed in 2014 by CDW Healthcare. EBM offers a framework for putting this data to good use, for example by better aligning clinical research with practice and continually assessing the results of any changes in approach.
EBM offers a road to better health for patients, with more consistent practices from providers and savings for payers. EBM can also support payers in feeling more confident that a given procedure is worthwhile and effective, allowing them to avoid common situations such as a treatment being denied based on incomplete evidence, leading to costlier ER visits down the line. This is another way in which EBM aligns with the goals of VBR.
As we have seen in our posts on EBM, it offers a useful set of practices for evaluating, applying and reviewing different sources of evidence in healthcare. RCTs are the ideal forms of evidence, but there are others - such as case studies and expert opinions - that may be incorporated, depending on the situation.
The evolution of EBM guidelines keeps current practices in line with the best available research and evidence. Working with a trusted Independent Review Organization (IRO) can further strengthen how you assess treatments and make informed decisions to promote high-quality care for everyone.
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