Evidence-based Medicine: from the Laptop to the Bedside

Brent W. Beasley, MD, FACPProgram Director, Internal Medicine Residency

University of Missouri—Kansas CityMedical Director, St. Luke’s Care

Case Presentation

• 41 year old internist who tries to keep up with reading journals is asked to admit a patient with community acquired pneumonia.

• Having attended a CME course recently in Sanibel Island, FL, she remembers hearing that new recommendations were released by pulmonologists…or was it infectious disease docs?

Problem

• Wishing she had stayed awake during that presentation,

• Wishing she had the handouts from the conference available,

• And, wishing that she wasn’t so dang busy,

• She considers her options…

ProblemShe could:A. Consult a pulmonologist—they’ll do the

best job.B. Do what she usually does. Start writing

orders and hope she gets it correct.C. Do a comprehensive Medline literature

search on the computer in the office and try to figure out the right approach.

D. None of the above?

Do Subspecialists Provide the Best Care for Pneumonia?

• This is a talk about Evidence-based Medicine

• What does the evidence say?

• Careful—this is a touchy topic and the literature is fraught with prejudice, bias, and mediocre studies!

Relationship of provider characteristics to outcomes, process, and costs of care

for community-acquired pneumonia

• Using Medicare claims data to ascertain – mortality, – readmissions, – use of procedures – physician consultations– costs of care.

• Adjusted for patient characteristics, comorbidity and microbial etiology.

• 22,294 pneumonia episodes studied, 30-day mortality was 17%.

Med Care. 1998 Jul;36(7):977-87Whittle J, Lin CJ, Lave JR, Fine MJ, Delaney KM, Joyce DZ, Young WW, Kapoor WN.

Relationship of provider characteristics to outcomes, process, and costs of care

for community-acquired pneumonia• 30-day mortality and readmission rates were

unrelated to:– hospital teaching status or– urban location or to– physician specialty.

• General internists and medical subspecialists used more procedures and had higher costs than family practitioners.

Med Care. 1998 Jul;36(7):977-87Whittle J, Lin CJ, Lave JR, Fine MJ, Delaney KM, Joyce DZ, Young WW, Kapoor WN.

Conflict Of Interest? The article came from the Pittsburgh Division of General Internal Medicine.

On the other hand, Michael Fine has carved a name out for himself in the care of patients with pneumonia.

(N Engl J Med 1997;336:243-50.)

The Fine Pneumonia Severity Index (PSI)

ProblemShe could:A. Consult a pulmonologist—they’ll do the

best job.B. Do what she usually does. Start writing

orders and hope she gets it correct.C. Do a comprehensive Medline literature

search on the computer in the office and try to figure out the right approach.

D. None of the above?

Should she just try to write the orders from memory?

• Well, just how good are physicians at remembering to include every recommendation?

• Not only that, but doesn’t it seem like too often when we “get it right” and write the correct orders, they just don’t happen? (more about why this happens later)

Physician awareness and self-reported use of local and national guidelines for

community-acquired pneumonia.• Surveyed 352 physicians at 7 Pittsburgh, PA

hospitals • 48% reported being influenced by ATS

guidelines• 20% reported using these guidelines• 48% were uncertain whether a local

pneumonia guideline existed• 28% of physicians who knew a local guideline

existed reported frequently using the guideline

J Gen Intern Med. 2003 Oct;18(10):816-23. LinksSwitzer GE, Halm EA, Chang CC, Mittman BS, Walsh MB, Fine MJ.

ProblemShe could:A. Consult a pulmonologist—they’ll do the

best job.B. Do what she usually does. Start writing

orders and hope she gets it correct.C. Do a comprehensive Medline literature

search on the computer in the office and try to figure out the right approach.

D. None of the above?

All Roads Lead to Rome!!!

UpToDate Editorial Policy

• Hierarchy of evidence – randomized trials of high methodological quality, – randomized trials with methodological limitations, – observational studies, and – unsystematic clinical observations.

• Inferences are stronger when the evidence is summarized in systematic reviews of the literature that present all relevant data.

http://www.uptodate.com/

UpToDate Editorial Policy

• Each topic has an expert in the area, and > two separate physician reviewers.

• Group performs a comprehensive review of the literature

• Studies selected based upon quality, the hierarchy of evidence, and clinical relevance.

• When high-quality systematic reviews are available, topics and recommendations rely heavily on these reviews.

http://www.uptodate.com/

UpToDate Editorial PolicyEvidence is derived from: • searching > 375 peer reviewed journals • databases including:

– MEDLINE, – The Cochrane Database, – Clinical Evidence, and – ACP Journal Club

• Guidelines• Published information regarding clinical trials: the FDA &

other federal agencies such as CDC & NIH • Proceedings of major national meetings • The clinical experience and observations of our authors,

editors, and peer reviewers

http://www.uptodate.com/

UpToDate Editorial PolicyValues and Preferences

"Evidence alone is never sufficient to make a clinical decision. Decision makers must always trade the benefits and risks, inconvenience, and costs associated with alternative management strategies, and in doing so consider the patient's values" -- Gordon Guyatt from McMaster University

http://www.uptodate.com/

UpToDate Editorial Policy• Make specific recommendations for

patient care when possible.

• “When there is no published systematic evidence available, recommendations are based upon the unsystematic clinical observations of our experts and reviewers, and on pathophysiologic rationale.”

http://www.uptodate.com/

UpToDate Editorial PolicyGrading Recommendations• Since February 2006--only a fraction of

topics have grades. • Grades have two components:

– number (1 or 2) reflecting the strength of the recommendation

– letter (A, B, or C) reflecting the quality of the evidence.

http://www.uptodate.com/

UpToDate Editorial PolicyUpdating

• Revised when new information is published, not by time schedule.

• ~40% of reviews are updated every 4 months.

• All reviews subjected to Peer Review

http://www.uptodate.com/

The Problem• I truly DO believe that this is the single

best way physicians can learn: start with a patient question, search a database, and discern the strengths and weaknesses of studies.

• However, does this internist have time to perform the literature search right now?right now?

• Between RVUs and patients waiting, family demands, and waiting messages…

ProblemShe could:A. Consult a pulmonologist—they’ll do the

best job.B. Do what she usually does. Start writing

orders and hope she gets it correct.C. Do a comprehensive Medline literature

search on the computer in the office and try to figure out the right approach.

D. None of the above?

IDSA/ATS Consensus Guidelines on the Management of CAP in Adults

“Implementation of Guideline Recommendations 1. Locally adapted guidelines should be implementedLocally adapted guidelines should be implemented to

improve process of care variables and relevant clinical outcomes. (Strong recommendation; level I evidence.)

…Consistently beneficial effects in clinically relevant parameters followed the introduction of a comprehensive protocol that increased compliance with published guidelines. The first recommendation, therefore, is that The first recommendation, therefore, is that CAP management guidelines be locally adapted and CAP management guidelines be locally adapted and implemented.”implemented.”

Mandell, et al. Clinical Infectious Diseases    2007;44:S27-S72

“Implementation of Guideline Recommendations

Documented benefits.      2. CAP guidelines should address a comprehensive set of comprehensive set of

elementselements in the process of care rather than a single element in isolation. (Strong recommendation; level III evidence.)

3. Development of local CAP guidelines should be directed toward improvement in specific and clinically relevant improvement in specific and clinically relevant outcomesoutcomes. (Moderate recommendation; level III evidence.)”

Mandell, et al. Clinical Infectious Diseases    2007;44:S27-S72

IDSA/ATS Consensus Guidelines on the Management of CAP in Adults

Plan

– Flowchart CAP direct admit process– Clarify understanding of CMS vs. JCAHO

definition of CAP antibiotic timing metric (round 1)

– Clarify process for identifying and establishing CAP antibiotic timing (round 1)

– Complete flowchart of processes for direct and ED admits

Design

• Collaborative practice agreement to auto-initiate CAP standing order set

• Increase use of CAP standing order set for direct admits – improve access to orders via Browser

• Call on-call beeper to reach the correct hospitalist for orders

• Move antibiotic order to top of CAP standing orders and include goal of administration w/in 4 hrs.

• Increase availability of antibiotics in Pyxis machines for units with high CAP volumes

• Pharmacy to place call to floor when med is available in Pyxis

What’s Wrong with this Picture?Among both physicians &

hospitals, higher pneumonia volume is associated with reduced adherence to selected guideline recommend-ations & no measurable improvement in patient outcomes.

Lindenauer PK, Behal R, Murray CK, Nsa W, PhD, Houck, PM, Bratzler DW. Volume, Quality of Care, and Outcome in Pneumonia. Ann Intern Med, 2006; 144(4):262-269.

Greater surgeon and hospital volumes were associated with improved outcomes for patients undergoing surgery for colorectal cancer.

Rogers SO, Wolf RE, Zaslavsky AM, Wright WE, Ayanian JZ. Relation of surgeon and hospital volume to processes and outcomes of colorectal cancer surgery. Ann. Surg. 2006 Dec;244(6):1003-11.

Saint Luke's HospitalAntibiotic within 240 Minutes for Pneumonia

First Quarter 2002 through Fourth Quarter 2004

64

56

51

53

50

6162

55

78

62

89

69

50

55

60

65

70

75

80

85

90

95

Ra

te

Measure

Community Acquired PneumoniaALOS With vs. Without Standing Orders

Calendar Year 2004

0

2

4

6

8

10

12

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

2004 Community Acquired Pneumonia Patients - No Standing Orders 2004 Community Acquired Pneumonia Patients - Standing Orders

Measure

Improve• 2005-06 SLH continued to have time-to-

abx rates of around 75% within 4 hours.• We have provided feedback to the ED on

specific cases in order to inform their processes.

• In April, they began a new throughput initiative and decreased ED times by 1.5 hours: triage protocols, nurse practitioner

• 2nd quarter 2007 our rate went to 95% (and was 100% in June!)

Improve• Denise Mogg, the Nurse Manager in

the ED,– “We have to change the culture. We

have to change the old ways of doing things.”

St. Luke’s Care Cardiology Evidence-based St. Luke’s Care Cardiology Evidence-based Practice Team Product: ACS OrdersPractice Team Product: ACS Orders

St. Luke’s Care Cardiology Evidence-based St. Luke’s Care Cardiology Evidence-based Practice Team Product: ACS OrdersPractice Team Product: ACS Orders

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