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Physicians Practice. Vol. 19 No. 6
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Evidence-Based Medicine Examined

Evidence-based medicine has been around for 16 years. So why are some still resistant to it?

By Shirley Grace | April 1, 2009


Indeed, about 5,000 new studies come off the press every single day. Some bear important proof of a new treatment for a heinous disease. Others might be useful, but the sample size is too small to be credible. Still others are good for lining your parakeet’s cage. How can you get to what you need expeditiously yet still perform your due diligence?

With a little help from some friends. That means seeking out high-quality resources you can trust to do some legwork for you, so you can quickly check the facts and apply them to your patient’s situations. But where exactly to turn?

Use guidelines. The clinical guidelines proffered by various specialty associations — as opposed to evidence-based medicine, per se — are what some physicians say amount to cookbook medicine. But the guidelines are based on the existing evidence, not the other way around, and they are formed by teams of doctors and researchers who spend their days sifting through all that data. The guidelines save you time.

You’ll find scads of evidence-based guidelines within these organization Web pages, and “all are free and easily accessible,” says Robert Goldszer, chief medical officer at Mt. Sinai Medical Center in Miami Beach. He agrees that evidence-based guidelines can be very helpful. “Even on smaller things, like treatment of upper respiratory infections,” he says. “If people really followed guidelines from evidence-based medicine, we would … be spending a lot less on antibiotics because we wouldn’t have [as many] resistant organisms; we wouldn’t have given so many antibiotics to people.

“That’s a very common issue with evidence-based medicine,” he continues. “Evidence-based medicine for upper respiratory infection is Tylenol, Sudafed, liquids, and stay in bed and it gets better. It’s not the Z-Pak.”

Another issue with guidelines is agreeing on them. Love of autonomy is a prime characteristic of many physicians. Is it possible to agree on standards of care? “It’s a challenge but it’s been done plenty of times by many, many organizations,” says Goldszer, including the CDC, the AMA, and a host of others.

Consider setting up practice-level guidelines to follow based on the guidelines of large, well-established organizations, including:

  • U.S. Department of Health and Human Services — the Centers for Medicare and Medicaid Services and the National Guidelines Clearinghouse;

  • Agency for Healthcare Research and Quality — U.S. Preventive Services Task Force

  • The Joint Commission — Independent, not-for-profit organization that certifies healthcare organizations and programs in the U.S.; and

  • Other large, “blue-chip” medical associations — The American Diabetes Association, the American Heart Association, the AMA, the ADA, and the like.
You can turn to your guidelines whenever you need to add heft to your clinical decisions, especially difficult patients. Show them exactly where you’re getting your facts from. Posting your guidelines — in the office, on your Web site, or both — can be a positive marketing tool, as it shows your practice does everything it can to operate thoughtfully.

Moreover, following proven protocols can protect you from legal threats. “If physicians adhere to guidelines and do what’s recommended by national organizations, then they’re much less likely to have liability,” says Goldszer. “They’re doing the ‘right’ thing. They’re doing the recommended standard of care. If you’re worried about malpractice — which many people are — if you adhere to the guidelines, then you’re practicing standard of care and you’re much safer that way. [Physicians] are worried about standardization, but everything you read about quality improvement is that standardization helps. Variation hurts us. Guidelines and evidence-based medicine are steps towards standardization, and away from variation.”

Use technology. If ever the use of technology made sense for the medical world, organizing and vetting research data might be the most important reason. An EMR, for example, is designed to do so much more than just store electronic records. Many systems include decision-support software architecture to help you treat your patients without wasting time.

Most well-implemented EMRs alert physicians to treatments a patient might need but is not getting, based on the patient’s stored data and regularly updated clinical guidelines.

Reputable EMR developers consult credible guideline sources to set up their alerts, so you can feel good about their basis. You can often customize them, too, to address special needs you may have with your local population or payers.

Still, those evidence-based alerts can be annoyingly intrusive. “Physicians may be getting a whole lot of alerts/reminders they don’t want to see,” admits Sarah Corley, chief medical officer for NextGen, an EMR maker whose alert system is called Healthmonitor. “That’s the difficult part of EMR development: Where’s the best place to present the information, and who should be seeing it? What works for one practice won’t work for another.”

You can put your own EMR data to work, too. “Good EMR software can make it a breeze to maintain a disease registry,” says Cyrus Peikari, a solo internist practicing in Dallas, Texas. “It can allow you to run reports to make sure your diabetics have a recent A1c, lipid screen, etc.” And you’ll know exactly how often and for whom you should be focusing, because you’re evidence-based. Not too much testing, and not too little.

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