putting evidence into practice1 a

Putting Evidence Into Practice; Case Management Works

Presented By:Linda S. Van Dillen RN, BA, CCMS&H Medical Management Services, Inc.

S&H Medical Management Services, Inc.

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Introduction

Evidence based medicine will be defined

Participants will learn about principles behind evidence based medicine

Case management plays a role in practice of evidence based medicine


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Overview

Evidence Based Medicine , whose origins extend back to mid-19th century Paris and earlier, remains a hot topic for clinicians, purchasers, planners and the public.

SUPPRESS-IVE??

COOK BOOK?

IVORY TOWER

$$$$OLD HAT?

IMPOSSIBLE?

FACTHUNCHEBM


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Vocabulary

Clinical Practice Guideline is a systematically developed statement designed to assist practitioner and patient make decisions about appropriate health care for specific clinical circumstances.


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Vocabulary (cont.)

Cost-Benefit Analysis converts effects into the same monetary terms as the costs and compares them.

Cost-Effectiveness Analysis converts effects into health terms and describes the costs for some additional health gain (e.g. cost per additional MI prevented).


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Vocabulary (cont.)

Randomized Controlled Clinical Trial a group of patients is randomized into an experimental group and a control group. These groups are followed up for the variables / outcomes of interest.


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Vocabulary (cont.)

Systematic Review is a literature review focused on a single question which tries to identify, appraise, select and synthesize all high quality research evidence relevant to that question.


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Vocabulary (cont.)

Evidence-Based Health Care extends the application of the principles of Evidence-Based Medicine to all professions associated with health care, including purchasing and case management.


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What Is Evidence Based Medicine? As defined by Dr. David Sackett,

evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.

The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.


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What Is Evidence Based Medicine? (cont.) By best available external clinical

evidence, Dr. Sackett states he means clinically relevant research, often from the basic sciences of medicine, but especially from patient centered clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens.


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Principles Behind Evidence Based Medicine Dr. Sackett states this type of

medicine is neither old-hat or impossible to practice.

Consider, an average physician may evaluate

100 – 200 patients/wk or 5,000 – 10,000 patients/yr


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Principles Behind Evidence Based Medicine(cont.)

1,000 New Medline Articles are published daily

3,000 New Papers are written each day

How does the physician or other health care providers keep up with the Increasing Medical Knowledge?


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Number of Articles on Hypertension cited in Medline by Year

0

1000

2000

3000

4000

5000

6000

7000

8000

1966 1976 1986 1996

Articles


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Too many patients Too many problems Too many journals Information overload No time to read


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We tend to read what we are familiar with

Avoid difficult issues Cannot be “cook book” medicine External clinical evidence can

inform, but can never replace individual clinical expertise.


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Principles Behind Evidence Based Medicine(cont.) It is this individual clinical expertise that

decides whether the external evidence applies to the individual patient.

Evidence based medicine is not cost-cutting medicine, but rather a method of looking for the most effective ways to improve the quality and quantity of patients’ lives.

Evidence based medicine is not restricted to randomized trials and meta-analysis.


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Principles Behind Evidence Based Medicine(cont.) The positive impacts are just

beginning to be validated and EBM will continue to evolve.

Traditional methods of reading journals and textbooks (already out of date) are not working, given the sheer volume of clinical literature.


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Evidence Based Medicine is practiced by adopting the habit of making selective, efficient, patient-centered searches for evidence and incorporating what stands up to scrutiny into everyday practice.


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Types of Research Performed to Objectify EBM

Many people regard clinical medicine and other aspects of health care as already “evidence based”, making logical decisions of diagnosis and treatment using scientific methods.


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Types of Research Performed to Objectify EBM (cont.) In the book titled, “Key Topics in

Evidence Based Medicine”, it is reported clinical decisions are based on a number of factors, not least the experience of the doctor and his teachers.


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Types of Research Performed to Objectify EBM (cont.) “The Natural History of the Sore

Throat” is to get better without intervention. However, if the patient is treated there is also a high likelihood he will get better, even if he is a little worse for a while (i.e. he has not reached the peak of his illness at the time of consultation).


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Types of Research Performed to Objectify EBM (cont.) Such a positive outcome reinforces the

patient’s and the doctor’s belief that the treatment has had an effect when they are probably experiencing and witnessing the natural history of disease.

In this example, the patient will not usually be harmed. However, use of antibiotics encourage resistant strains to evolve, and there is the cost of the doctor-time and treatment.


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Types of Research Performed to Objectify EBM (cont.) If data from a good randomized

controlled trial conflicts with this experience we can possibly conclude that we did not appreciate the significance of the natural history of disease.


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Types of Research Performed to Objectify EBM (cont.) However, if there is a conflict, there

remains the possibility the evidence is not reliable.

This is one good reason why it is important to develop skill at searching for and appraising evidence.


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Types of Research Performed to Objectify EBM (cont.) Randomized controlled trial – “Gold

Standard” design, e.g. Randomized drug trial.

Cohort study – second best study design, where one or two groups are exposed to the agent and followed for a period of time.

Systematic review of randomized trials.


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Types of Research Performed to Objectify EBM (cont.)

Systematic review of observational studies addressing patient outcomes

Physiological studies Unsystematic clinical observations


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How Does the Case Manager Find the Evidence for “Best Practices”?

It is important to note, the Case Manager is NOT to present themselves as a physician, or a “director” of care.


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How Does the Case Manager Find the Evidence for “Best Practices”? (cont.) The RN Case Manager has the capability

to provide a detailed summary of medical records, ascertain if any records are missing, and request specific information from the physician as to specific diagnosis, objective findings, diagnostic studies required, treatment plan, projections for treatment, rehabilitation and causation issues (when appropriate).


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How Does the Case Manager Find the Evidence for “Best Practices”? (cont.) The RN Case Manager can make

recommendations as to if the treatment plan proposed does not appear to be within usual and customary expected standards, and when it is appropriate to coordinate a 2nd opinion or IME, to definitively delineate the above issues.


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How Does the Case Manager Find the Evidence for “Best Practices”? (cont.) What type of references are utilized

to support these recommendations? The internet is a rich source of

medical information. However, care must be exercised interpreting this information, as it may not have been subject to a rigorous evaluation process.


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How Does the Case Manager Find the Evidence for “Best Practices”? (cont.)E-Journals BMJ – Free access, searchable, full text

with PDF. www.bmj.com JAMA - Free abstracts and some full text

to non-subscribers www.ama-assn.org/public/journals/jama/jamahome.html/

Lancet - Free abstracts and some full text to non-subscribers www.thelancet.com


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How Does the Case Manager Find the Evidence for “Best Practices”? (cont.) PubMed Central – web-based

archive of a growing number of full text articles provided by publishers and directly linked to Medline.

www.pubmedcentral.nih.gov/ Evidence Based Medicine Resource

Center http://www.ebmny.org/resource.html


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How Does the Case Manager Find the Evidence for “Best Practices”? (cont.)Online Databases Medline

www.ncbi.nlm.nih.gov/entrez/query.fcgi Cochrane Collaboration

www.cochrane.org/cochrane/ccweb.htm#CRG

www.uptodate.com www.acpmedicine.com


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Subscription Resources

Official Disability Guidelines http://www.disabilitydurations.com/

Medical Disability Adviser http://www.rgl.net/services.html


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Example of Utilization of EBM In the Mental Health Weekly May 2,

2004, it is reported Oregon legislators adopted a law in 2003, requiring the state Office of Mental Health and Addiction Services and four other state agencies to demonstrate that set percentages of their program dollars support evidence-based approaches.


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Example of Utilization of EBM (cont.) For the two-year budget cycle that

begins July 1, 2005, the Oregon state behavioral health agency will have to show that at least 25 percent of its program funding supports evidence-based programs. That percentage will rise to at least 50 percent in the biennium beginning July 1, 2007, and at least 75 percent in July 2009.


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Pros/cons of EBM Many times the goal of making clinical

decisions based on evidence can be impaired by the restricted quality and scope of the “best available evidence.”

EBM may lead to major abuses that produce inappropriate guidelines or doctrinaire dogmas of clinical practice.


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Developing a Working Relationship Between the Case Manager and the Physician

Discussion of Methods for communication with the physician

Phone contact Written correspondence In-person meeting How do you get the physician to listen to

you? Importance of certification Does your CM understand the principles of

EBM?


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Example of S&H Use of EBM MD Treatment and RTW Projections: (include

treatment and RTW projections as stated by the MD) Utilization Review Analysis: (Contrast MD Treatment

Plan & RTW Projections with MDA or other EBM info) MDA Projections for RTW:

RN Concerns/Comments/Observations/Recommendations: (insert information summarizing Barriers, Recs, etc.)

Work Demand

Sedentary Light Medium Heavy Very Heavy

Timeframe


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Summary

Evidence Based Medicine is a method of objectifying medical treatment and looking for current best evidence, but always making sure individual clinical experience is incorporated.


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Summary (cont.)

An RN Case Manager can be invaluable in assisting with determination of the need for additional research, performing the necessary research and coordinating a second medical evaluation to delineate the best medical practice for the specific medical treatment in question.

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