Challenges to adopting evidence-based medicine
Despite aligned financial incentives and well-intentioned clinical practice guidelines, physicians are sometimes slow to utilize evidence-based medicine in clinical practice. This is especially true when new evidence challenges conventional wisdom.
Consider, for example, a well-publicized study that examined invasive therapy for stable coronary artery disease. In 2007, strong evidence emerged that found a three-drug therapy for chronic stable angina could be as effective as invasive placement of a coronary stent. However, a decade later, cardiologists acknowledge that the (less-expensive) three-drug therapy remains underutilized, while stents were overutilized. Indeed, as recently as 2016 the American College of Cardiology reported that close to 50 percent of stents for non-acute patients were placed without appropriate indications.
Despite strong evidence, physicians often take years to change practice habits. Evidence adoption is further delayed when doctors cannot easily translate population-based guidelines to the unique needs or preferences of an individual patient. Making the best and most meaningful evidence guidance applicable to a specific patient is hardly straightforward, as suggested in a recent systematic review of 48 studies and over 13,000 clinicians. According to the authors, clinicians overestimate the benefit of a test or treatment 32 percent of the time and underestimate the risk of harm 34 percent of the time.
Leveraging curated evidence to achieve clinical and financial goals
The incorporation of evidence-based medicine into everyday practice remains a challenge, but physicians now have increased access to more tools to help them evaluate the relative value of different interventions.
Consider the Choosing Wisely campaign, which the American Board of Internal Medicine launched in 2012. ABIM publishes a list that includes specialty society warnings about several hundred tests or treatments that should be avoided under specific circumstances. Physicians able to stay abreast of pertinent details related to their specialty are more likely to select interventions that improve care and optimize resources.
Other sources of evidence-based guidelines include the Cochrane Collaboration, specialty society “journal clubs,” and commercial providers of order sets and care plans. Such organizations perform systematic evaluations of new studies to assess their importance for patient outcomes. In addition, Right Care Alliance, the NNT, and similar coalitions work to identify and reduce overutilized healthcare interventions by clarifying the risks and benefits of various tests and treatments.
By arming physicians with evidence-based guidelines, they are better-equipped to make clinical decisions that are cost-effective and drive high-quality outcomes. In order to achieve Triple Aim goals and value-based care objectives, healthcare organizations must leverage available technologies and resources and give their physicians ready-access to the most current evidence-based data.
Ross Ellis, MD is an ABIM-board certified internist and medical director at Zynx Health to help implement evidence-based care guidance across a broad range of health systems in the U.S., Canada, and the Middle East. In his own practice in eastern Pennsylvania he has helped manage clinical decision support for EHR-based workflows. Ellis completed an MD degree, MPH degree, and residency training at Columbia University.