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

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

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

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)

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

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

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

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?

Three questions: 1. Why do professions develop clinical practice guidelines? 2. What is the effect of clinical practice guidelines on medical care? 3. Do patients benefit from EBM?

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

Source: Wennberg 1999

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?

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

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

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

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

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.

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

Thank you !