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How evidence-based guidelines impact real-world care

Evidence-based care offers clinicians the most effective and efficient way to treat patients for the best outcome, however, not all physicians follow this route. In this guest post, Howard Willson, MD, MBA, senior VP of customer success at a company that provides evidence-based, clinical decision support system solutions, shows why evidenced-based care is the best option for patients and hospitals.

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What physicians don’t know can hurt them or, more directly, their patients.

Healthcare interventions based on evidence are considered the gold standard for high-quality patient care. By eliminating variations from evidence-based standards, clinicians increase the likelihood of effective outcomes and minimize the risks of complications that compromise a patient’s health and safety.

But too often, and for various reasons, physicians don’t follow evidence-based standards, putting their patients at risk of substandard care and burdening the overall U.S. health system with avoidable costs. For example, a recent study co-authored by influential Harvard economist David Cutler and published in the American Economic Journal: Economic Policy estimated that 35% of all Medicare spending for end-of-life care and 12% of spending for heart attack patients is associated with physician beliefs unsupported by clinical evidence.

Ultimately, it’s understood that medicine is both an art and a science, but the challenge is that many clinicians overemphasize the “art” at the expense of the “science” by relying too heavily upon their own experiences.

How did we get here?

Hospital physicians bring with them different backgrounds, training and experience. They learn how to approach certain types of cases or conditions based largely on what they’ve been taught and what they remember from medical school and residency.

We now know this isn’t necessarily the best way to practice medicine. What doctors think is best for a patient doesn’t always align with what the research shows is best. When researchers study a disease or a condition, they typically assess more patients than any one doctor will ever treat.

Further, standards of care change over time, so that what doctors once thought was the best therapy, even a few years ago, may now be considered harmful.

As an example, for decades, a daily dose of aspirin was considered a wise approach to preventing a heart attack, stroke or other cardiovascular event. However, a recent guideline by the American Heart Association advises against daily, preventive aspirin for many individuals because newer research has shown that this may cause more harm than good. The benefit from taking a daily low-dose aspirin is offset by the danger of internal bleeding and other side effects in individuals considered to be at only low- or moderate-risk for heart disease.

Among busy, practicing physicians, staying attuned to the latest medical literature updates can be challenging, which is one reason there exists a significant lag before newer evidence-based approaches are widely adopted. To blame physicians for this situation is an oversimplification of the issue. The challenge of staying current with medical research literature is more than any one person can achieve.

In an illuminating study published in the Journal of the Medical Library Association, researchers estimated the volume of medical literature potentially relevant to primary care published in a single month and the time required for physicians trained in medical epidemiology to evaluate it. According to the researchers, physicians would need approximately 627.5 hours per month to evaluate all the articles!

One patient’s journey shows the value of evidence-based standards

To further explain the value of evidence-based care standardization, let’s examine the care journey a hypothetical patient with heart failure may take under two similar, but slightly different, scenarios: one in which the patient’s physician follows evidence-based guidelines and one in which the physician does not.

Under the non-evidence-based scenario, the patient (64-year-old Adam Jones) presents to his primary care physician with dyspnea (shortness of breath) on exertion. An exam reveals trace pedal edema and bilateral crackles at the lung bases, and Jones is diagnosed with suspected heart failure. Jones is prescribed the diuretic, furosemide, which prevents the body from absorbing too much salt. The drug improves Jones’ symptoms for a period of time, but they later worsen and he ends up presenting at the emergency department with acute dyspnea and is admitted with exacerbation of heart failure. Jones responds to intravenous diuresis (increased urination) and is discharged home.

The evidence-based scenario differs in just a few notable, but important, steps, starting with the prescribing of furosemide. Had the physician followed evidence-based guidelines, she would have also prescribed an ACE inhibitor and beta-blocker, per recent guidelines published by the American College of Cardiology and other groups that recommend all three medications for patients with heart failure.

However, despite following the current standards for guideline-directed therapy, Jones still develops acute dyspnea, and is admitted to the hospital with exacerbation of heart failure. At this point, the paths in these two scenarios begin to diverge more significantly. Jones’ oral medications are discontinued until he is stabilized on an intravenous diuretic, and then resumes taking the three medications. Jones is referred to an outpatient cardiac rehabilitation center on discharge, and stops receiving the ACE inhibitor while starting on an ARNi (sacubitril-valasartan), another type of recommended drug.

While the distinctions between the two journeys are subtle – especially to laymen – the effect on the patient in terms of complications, costs and outcomes may be substantial.

How to promote evidence-based guidelines

Ultimately, hospital leadership must take the lead in establishing an environment and creating interventions that guide clinicians toward following evidence-based standards. These interventions may take the form of clinical decision support or alerts that prompt physicians to make point-of-care decisions consistent with evidence-based guidelines.

Evidence-based guidelines ensure that patients will be cared for in the same manner regardless of who treats them and where the care is provided. However, it is unrealistic to expect physicians to do this independently. Hospital leaders must work in tandem with physicians to determine the best way to integrate evidence-based practices into their workflows. The potential payoffs include reductions in readmission rates, lengths of stay, mortality and expenses.

Howard Willson, MD, MBA, senior VP of customer success at Zynx Health, a provider of evidence-based, clinical decision support system solutions.

 

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