Collaboration key to delivering evidence-based medicine
Barriers to delivering evidence-based health care and strategies to overcome these barriers were important topics discussed this week in U.S. medical journals.
About 55% of adult patients do not receive recommended care, Sharon Straus, MD, a geriatrician at St. Michael's Hospital in Toronto, estimated extrapolating data from U.S. studies. “Failures to use research evidence to inform decision making are apparent across all […] key decision maker groups,” she and colleagues wrote in the Journal of Clinical Epidemiology.
Underprescibing cholesterol-lowering statins despite evidence that these drugs decrease the risk of death after stroke, and ineffective antibiotic overuse to treat children with upper respiratory tract infections are just two examples Straus cited to explain how health care providers are failing to implement research knowledge in practice.
“The realities of health care systems are that we have insufficient resources to do everything and thus we must work with stakeholders including patients, public, clinicians and policy makers to establish an explicit prioritization process for knowledge translation activities,” Straus, who is also the director of knowledge translation at St. Michael's, said in a press release.
Cost, education, scarce resources and a very large body of research evidence are all barriers to putting evidence into practice, the researchers noted. They called for further study to better understand gaps in decision making, when care guidelines should be updated, how to improve guideline implementation, and strategies for translating knowledge into practice.
Evaluating quality improvement efforts
Despite producing only modest benefits, a quality improvement trial published online first in the Journal of the American Medical Association, is a step in the right direction.
Damon C. Scales, MD, PhD, of the University of Toronto and Sunnybrook Health Sciences Center, and colleagues conducted a cluster-randomized trial at 15 community hospitals in Ontario, Canada, to determine if an intervention could increase adoption of six evidence-based ICU care practices.
“Nonacademic hospitals face larger barriers to implementing evidence-based care because of heavier individual clinician workloads and fewer personnel devoted to collaborative continuing education activities,” the researchers wrote.
The six ICU practices the intervention aimed to improve included:
- Ventilator-associated pneumonia (VAP) prevention
- Deep vein thrombosis (DVT) prevention
- Sterile precautions for central venous catheter insertion to prevent bloodstream infections
- Daily spontaneous breathing trials to decrease mechanical ventilation duration
- Early enteral nutrition
- Daily pressure ulcer risk assessment.
All ICUs were randomly assigned to two groups, each of which received a videoconference-based intervention, including audit and feedback, expert-led educational sessions and algorithms designed to sequentially improve care.
Each group targeted a new practice every four months, and acted as the control for the other group while it simultaneously targeted one of the other practices.
Researchers found that overall adoption of targeted practices was better among intervention ICUs than control ICUs (summary ratio of ORs=2.79, 95% CI:1.00-7.74), with the best results noted for VAP prevention practices (90% of patient-days in last month of intervention vs. 50% in first month; OR=6.35, 95% CI:1.85-21.79) and catheter related bloodstream infections (70% vs. 10.6% of patients with central lines; OR=30.06, 95% CI: 11.00-82.17).
There were no notable changes in adoption of the other practices; however, the researchers noted that compliance rates were already high for many of these at baseline. Performance improvements varied by ICU.
“Future large-scale quality improvement initiatives should choose practices based on measured rather than reported care gaps, consider site-specific (vs. aggregated) needs assessments to determine target care practices, and conduct baseline audits to focus on poorly performing ICUs, which have the greatest potential for improvement,” the researchers wrote.
Lessons for the future
In an accompanying editorial, J. Randall Curtis, MD, MPH, of Harborview Medical Center in Seattle, Wa., and Mitchell M. Levy, MD of Rhode Island Hospital, in Providence, praised the study for it's state-of-the-art methods, appropriate complexities, and positive findings.
Funded by the Ontario healthcare delivery system rather than a research-funding agency, Curtis and Levy called the study, “an important model for the future. ” They said demonstration projects entailed in the Affordable Care Act to ensure health care quality and cost control “will require the same type of rigorous high quality research used by Scales and colleagues.”