Following the Evidence

Working With the Evidence

The first key to improving care with evidence-based medicine is to make use of the latest, most comprehensive medical research. The gold standard is the randomized controlled trial, which has mechanisms to filter out bias, inconsistencies, or study subjects that could skew the results. Less rigorous forms of research include cohort studies that follow large populations over time, and meta-analyses, in which researchers examine the results from many studies on the same subject.

When the best research indicates that a specific treatment is optimally effective, care guidelines are created. The guidelines, also called clinical pathways, are general recommendations or more detailed protocols on how care should be administered for similar patients with a certain disease or condition.

Hundreds of guidelines are produced by the government, disease-advocacy groups such as the American Cancer Society, and professional associations such as the American College of Obstetricians and Gynecologists. However, the guidelines offered by these organizations don’t always agree.

To help Minnesota hospitals and clinics implement the best clinical practices, the Institute for Clinical Systems Improvement (ICSI), a Bloomington-based nonprofit, was established in 1992. It’s funded primarily by Eagan-based Blue Cross and Blue Shield of Minnesota, HealthPartners, and Minnetonka-based Medica Health Plans.

The Institute sets up committees of medical practitioners to look at various guidelines and the research backing them. It has now created 56 guidelines of its own, mostly for treating common chronic conditions such as low-back pain, depression, asthma, and osteoporosis. Many ICSI guidelines are identical or similar to those from national organizations. The institute allows local health care providers to shed the burden of creating clinical guidelines in house. Isham says HealthPartners hasn’t created a guideline of its own since ICSI’s founding.

The state is also getting more involved in evidence-based medicine. The Minnesota Legislature gave the Department of Human Services $2 million in 2005 to help it provide better care for the Medicaid clients it serves. The money was used to hire a medical director, set up a health services policy council, join a multi-state consortium focused on evidence-based research, and provide coordinated services for people at high risk of hospitalization because they have multiple conditions. Brian Osberg, assistant commissioner at the Department of Human Services, says the state wants the medical community to develop more care guidelines for the large number of geriatric, disabled, and minority clients it serves, because few guidelines exist for those groups now.

Nuts and Bolts

Evidence-based medicine will improve medical care only if health care providers commit to using the guidelines. The process of creating the guidelines locally is helping to speed their adoption.

“The process is as important as the outcome because it increases the likelihood of buy-in by practitioners,” says Dr. Gary Oftedahl, the institute’s medical director. “The resistance to guidelines is less now because medical providers see that the guidelines are backed by evidence.”

About three-fourths of Minnesota doctors work for organizations that belong to the institute, and many doctors trust the process because their colleagues are part of the institute’s rigorous research reviews.

Putting the guidelines into practice means doctors must embrace change in their offices. The current push to computerize patient records assists doctors in adhering to clinical guidelines. When a doctor pulls up a patient’s record on a computer in the examining room, a prompt might ask if a certain test has been done or respond to a prescription order.