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Tuesday, 20 July 2010

Evidence Based Planning and the Obama Protocols

Evidence Based Planning: How it Impacts Health Care
EBP: What it is
Evidence based planning is the catch phrase of the health care reform movement and this article explains what it means and how it is applied in health care processes. The Institute of Medicine or the IOM defines quality of care as “the degree to which health services for individuals and populations increase the likelihood of desired outcomes and are consistent with current professional knowledge”. Evidence based planning is harnessing the enlightenment gained from sharing scientific and medical practice information and using it to optimize clinical and operational procedures to improve results. The health care reform mandates in 2010 have provisions for increased transparency and optimization of service delivery, which can only be achieved by deploying the best practice protocols by diagnosis, whether it is heart disease or diabetes through the evidence based planning process. Certainly the words “best practice” are not offensive, but the beast rears its head when someone other than the local practitioner suggests a change in practice or patient protocols. However, this method of protocol review is an ongoing drama that has been and continues as the singular best method to reach out and impact treatment patterns. Large integrated health care organizations like Kaiser, Group Health Cooperative, or the Veterans Administration already have working committees who meet regularly to review data, test protocols, make recommendations for changes, and deploy the innovations throughout the organization. Hospitals also have multi-disciplinary committees who meet to figure out how to enhance patient outcomes by reviewing and adopting the best data driven practices and not all clinicians are happy about changing their patient practices as a result of the scrutiny.

Health System Impact

Evidence based planning is the practice of critical review of scientific literature (study data) to obtain advances in medical care protocols and then developing a method for localized testing and adoption within a health care facility or system. EBP is a process, not a single product driven task. The act of planning is a verb and applying best practice evidence in that process enhances institutional performance metrics. This means that patients who are the beneficiary of best practices live longer and with fewer complications than those who don’t, by a population standard.

Reducing the Patient’s Chance of Dying
As an example, when I was working on my MHA degree I took an evidence based planning course at the University of Washington School of Public Health and our EBP project reviewed data on Secondary Myocardial Infarctions (heart attacks) to develop a plan to reduce the likelihood of the second heart attack. We reviewed a significant body of information, including several dozen peer reviewed articles, and a European study which had measured time to treatment and long term prognosis for myocardial infarction patients . In our EBP project we learned that if patients registered in a follow-up program, especially a national database (like the Minnesota Heart Institute Registry), saw a cardiologist for medication management, and obtained appropriate medication, their chances of a second heart attack were 6% less than patients who did not follow these protocols. Our research included a comprehensive review of 40,684 admissions in Pennsylvania hospitals from a study in 1993 . The study cited an estimated cost savings to the Pennsylvania Medicaid program was $71,970 just by improving compliance for prescribing and administering beta-blockers. We also discovered that MI patients who obtained their three month follow-up visit were 57% less likely to die than patients who did not come in for their check-up. A retrospective cohort study (means they are reviewing historical patient data to draw conclusions) in Scotland, showed a significant difference in patient outcomes post discharge if they were treated by a cardiologist. Now it doesn’t take a rocket scientist to figure out this is a huge difference in performance, which has a significant impact on the cost of health care, when you consider that the Association of Health Research for Quality (AHRQ) estimates that 50% of Americans die from heart disease.

Implications for Medicare, which is the single largest cost driver in US Health Care

Heart disease is expected to remain the leading cause of death for the USA until 2020. By improving the outcome of cardiac patients we can save literally, millions of lives, and this is accomplished by evidence based planning. The beta-blocker protocol alone could save state Medicaid agencies 3.7 million dollars in a single year. This is an example of how government policy, drives reimbursements that impact which treatments patients receive, which can be life saving as well as monetarily more effective.

Another example of the application of evidence based planning was in 2005, when Medicare created incentive reimbursements ($6,000 per patient) for the administration of the drug tPA within three hours of a stroke, because patient recovery and mortality were significantly improved by this process. This was a way to get the attention of hospital administrators and improve surveillance and dispensing of this drug within the window of time to provide the biggest clinical impact.

Currently Medicare has demonstration projects reviewing how to improve chronic disease management for diabetics and other disease management programs, to improve patient management and Medicare health system management.

Why We Want Evidence Based Planning

The value we will get for our health care contributions, whether they are premiums, tax allocations, or fees for direct services are directly affected by the efficiency and cost of services in any health care system. It is in our best interest in terms of patient mortality (death) and morbidity (other complications) to seek care from institutions who are openly seeking to adopt the best practices world-wide for the management of your condition. The 2010 health care reforms under the Obama Administration specify and encourage the communication of performance metrics and the adoption of best practice clinical protocols to give you the best value for your money. Sounds great, so why isn’t everyone excited about this process to save money and improve our clinical outcomes when we have treatment? The conservative think tank Heritage Foundation, criticizes the Institute for Comparative Effectiveness, created by the Obama reforms to use population based research, as I previously explained in my cardiac example, as a bureaucratic intervention. This is not an accurate statement as evidence based planning is a science based discipline reviewing published studies under the Cochrane Central Registry of Controlled Trials and Medline Database among others to discern performance difference of significant impact on populations. The Institute for Comparative Effectiveness will review these science findings, make comparative information available to clinicians, insurance companies, and patients as a part of enhancing communication about patient procedural outcomes and system processes. The agency will coordinate with the National Institute of Health, NIH and Agency for Health Research and Quality, AHRQ as well as other expert sources to assimilate, measure, and distribute data on optimizing medical system performance. Why wouldn’t you want to have a resource to cull and present current international data about disease management and procedural outcomes? Sure it will cost a bit of your tax dollars, but a lot less than the ordnance in Iraq or Afghanistan.

The Institute for Comparative Effectiveness

The real value in the Institute for Comparative Effectiveness is the initiative in linking economic cost benefit analysis to health care delivery protocols in order to reveal the most efficacious methods. This means cutting waste, reducing unnecessary procedures, resourcing facilities appropriately (we don’t all need the DaVinci surgical robot), and improving surveillance of illness to slow disease progression. Yes, it will put the spotlight on health care suppliers, insurance companies, and other providers, but if we really intend to address the grossly high cost of the United States health care system(more than any other country and with poorer results in many areas), this is necessary. The folks who are using the scare tactics about evidence based medicine are trying to get a toe-hold in the “old each-practice-doing-what-it-wants” method of dispensing health care. That process is too expensive and the degree of variations in dispensing health care in this haphazard fashion do not create the same proportion of patient improvements as adopting optimal best practices for a society. Medicare did the right thing by rewarding hospitals who were administering tPA for stroke victims within the optimal window for efficacy and hopefully this new institute will help identify and spread other improvements to American health care as well. This is a first step in some analysis on effective cost cutting measures for United States health care.

What you can do

Use your fingers and do some research on the internet, go to reputable sites like AHRQ or NIH and educate yourself about your condition before your follow-up appointment after your initial diagnosis. When you meet with your clinician, ask about best practices and see what they say. If you are uncomfortable with the response, ask more questions, or consider getting a different clinician. You can have an impact on your health and your wallet if you do a little bit of research and ask the investigative questions. And to those who say evidence based planning is bad, I hope you visit a health care facility that isn’t using global best practice protocols. Good Luck!

This article was written by Roberta E. Winter, MHA, MPA, a health policy analyst in Seattle, Washington and may be reprinted with her permission. 7/13/2010


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