Crossing the Quality Chasm A New Health System for the 21st Century (2001) / Chapter Skim
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6 Applying Evidence to Health Care Delivery
6 Applying Evidence to Health Care Delivery
Pages 145-163
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From page 145... ...
Many promising private- and public-sector efforts now under way, including the Cochrane Collaboration, the ACP Journal Club, and the Evidence-Based Practice Centers supported by the Agency for Healthcare Research and Quality, represent excellent models and building blocks for a more comprehensive effort. Yet synthesizing the evidence is only the first step in making knowledge more usable by both clinicians and patients.
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From page 146... ...
The development of a more effective infrastructure to synthesize and organize evidence around priority conditions and to improve clinician and consumer access to the evidence base through the Internet offers new opportunities to enhance quality measurement and reporting. A stronger and more organized evidence base should facilitate the development of valid and reliable quality measures for priority conditions that can be used for both internal quality improvement and external accountability.
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From page 147... ...
In response to concerns that this definition failed to recognize the importance of other factors in making clinical decisions, more recent definitions explicitly incorporate clinical expertise and patient values into the decision-making process (Lohr et al., 1998~. Contemporary definitions also clarify that "evidence" is intended to refer not only to randomized controlled trials, the "gold standard," but also to other types of systematically acquired information.
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From page 148... ...
Systematic Reviews Systematic reviews are scientific investigations that synthesize the results of multiple primary investigations. Conduct of a systematic review to answer a specific clinical question generally involves four steps (Cook et al., 1997~: · Conduct of a comprehensive search of potentially relevant articles using explicit, reproducible criteria in the selection of articles for review · Critical appraisal of the scientific soundness of the research designs of the primary studies, including the selection of patients, sample size, and methods of accounting for confounding variables (Cook et al., 1997; Lohr and Carey, 1999)
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From page 149... ...
. The Cochrane Collaboration is an international network of health care professionals, researchers, and consumers that develops and maintains regularly updated reviews of evidence from randomized controlled trials and other research studies (Cochrane Collaboration, 1999~.
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From page 150... ...
The Database of Abstracts of Reviews of Effectiveness includes structured abstracts of systematic reviews that have been critically appraised by the National Health Services Centre for Reviews and Dissemination in York, England; the American College of Physicians' Journal Club; and the journal Evidence-Based Medicine. The library also includes a registry of bibliographic information on nearly 160,000 controlled trials that provide high-quality evidence on health care outcomes.
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From page 151... ...
Judgment must be exercised in this process because the evidence base is sometimes weak or conflicting, or lacking in the specificity needed to develop recommendations useful for making decisions about individual patients in particular settings (Lohr et al., 1998~. In an effort to organize information on practice guidelines and to identify those having an adequate evidence base, the Agency for Healthcare Research and Quality, in partnership with the American Medical Association and the American Association of Health Plans, has developed a National Guideline Clearinghouse, which became fully operational in 1999 (Eisenberg, 2000a)
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From page 152... ...
Applications in the first category and most applications to date in the second category deal with less complex and frequently occurring clinical decisions. The software required to assist clinicians and patients with these types of decisions can be constructed using relatively simple rule-based logic, often based on practice guidelines (Delaney et al., 1999; Shea et al., 1996~.
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From page 153... ...
In a meta-analysis of 16 randomized controlled trials, computer reminders were found to improve preventive practices for vaccinations, breast cancer screening, colorectal cancer screening, and cardiovascular risk reduction, but not for cervical cancer screening or other preventive services (e.g., glaucoma screening, TB skin test)
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From page 154... ...
The cost of maintaining updated syntheses of the evidence for most conditions and translating these syntheses into decision rules has been prohibitively high for commercial developers of these systems. As discussed above, however, interest in evidence-based practice has led to a logarithmic increase in systematic reviews of the clinical evidence on particular clinical questions, which are available in the public domain.
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From page 155... ...
Fourth, the extraordinary advances achieved in molecular medicine in recent years will further increase the complexity of both the evidence base and the clinical decision-making process, making it imperative that clinicians use computer-aided decision supports. Molecular medicine introduces a huge new body of knowledge that will affect virtually every area of practice, and also opens up the possibility of developing individualized treatments linked to a patient's genetic definition (Rienhoff,2000~.
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From page 156... ...
It is estimated that about 30 percent of MEDLINE searches are by members of the general public and students, 34 percent by health care professionals, and 36 percent by researchers (Lindberg, 1998~. In 1998, NLM added 12 consumer health journals to MEDLINE to increase its coverage of information written for the general public, and also launched MEDLINEplus, a Web site specifically for consumers (Lindberg and Humphreys, 1999~.
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From page 157... ...
The National Committee for Quality Assurance, through its Health Plan Employer Data and Information Set, makes comparative quality data available on participating health plans and includes such measures as childhood immunization rates, mammography rates, and the percentage of diabetics who had an annual eye exam (National Committee for Quality Assurance, l999~. The Joint Commission on the Accreditation of Healthcare Organizations sponsors the ORYX system for hospitals, which includes measures such as infection rates and postsurgical complication
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From page 158... ...
As systematic reviews, development of practice guidelines, and efforts to disseminate evidence focus increasingly on priority conditions a unit of analysis that is meaningful to patients and clinicians so, too, must accountability processes. To date, efforts to make comparative quality data available in the public domain have focused on types of health care organizations, for the most part health plans and hospitals, and, as noted above, measurement of a limited number of discrete quality indicators for these organizations.
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From page 159... ...
It will be important for the National Quality Forum, a recently created public-pnvate partnership developed to foster collaboration across public and pnvate oversight organizations, to consider carefully how best to align comparative quality reporting with the developing infrastructure in support of evidence-based practice and consumer-centered health care. The National Quality Forum, a notfor-profit organization established in 1999 with the participation of both public and private purchasers, is currently developing a strategic measurement framework to guide the future development of external quality reporting for purposes of accountability and consumer choice (Kizer, 2000~.
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From page 160... ...
Systematic Reviews: Synthesis of Best Evidence for Clinical Decisions.
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From page 161... ...
Effects of Computer-Based Clinical Decision Support Systems on Physician Performance and Patient Outcomes: A Systematic Review.
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From page 162... ...
Asessing "Best Evidence:" Issues in Grading the Quality of Studies for Systematic Reviews. Journal on Quality Improvement 25(9)
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From page 163... ...
A Meta-Analysis of 16 Randomized Controlled Trials to Evaluate Computer-Based Clinical Reminder Systems for Preventive Care in the Ambulatory Setting. JAm Med Inform Assoc 3(6)
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