Evidence-based medicine in the US healthcare industry: Lessons for India
Dr Saji Salam

The goal of EBM is to equip physicians and patients with the latest researched information, and guidelines for practice to assist them in effectively and pro-actively treating health conditions

According to the Institute of Medicine’s (IOM) report, ‘To Err Is Human: Building a Safer Health System,’ between 44,000 and 98,000 people die each year in the US as the result of clinical errors. In addition, the problem of clinical errors increases the cost of healthcare delivery by causing unnecessary complications that increase length of stay and resource consumption. Further, it can be damaging to staff morale and have a negative impact on caregiver recruitment and retention. The report created a shock wave in the healthcare industry in the US prompting regulatory bodies, vendors and consultants into action. One of the outcomes of the report has been a renewed focus on evidence-based medicine.

What is EBM?
EBM is the application of current best evidence from clinical research to the management of patient care. It takes into account patient preferences and the physician’s experienced judgement. The goal of EBM is to equip physicians and patients with the latest researched information and guidelines for practice to assist them in effectively and pro-actively treating health conditions. Progress in the implementation of EBM has been slow due to various reasons, most important being resistance from physicians.

Implementation plan of EBM
Selection criteria: Ident ify those conditions that will benefit most from the application of EBM. A good place to start is where the most prevalent and costly diseases exist within the population and for which evidence shows a great deal of variation in practice patterns.

Research
It does not make sense to reinvent the wheel. Doing research on the work done by peers can throw light on the existing guidelines. These guidelines provide description or standard specifications for care of patients with specific diseases and have been developed through a formal, consensus-building process that incorporates the best scientific evidence of effectiveness and expert opinion available.

Evaluate practicality
Many guidelines look good on paper, however the challenge is in identifying the ones, which can be actioned effectively to produce visible results.

Market the idea
It is critical at this juncture to provide the information to all concerned in the continuum of care and enlist their support. Marketing the plan internally and obtaining necessary goodwill for action can be a challenge. It would be a good idea to provide statistics of success stories if any in other organizations.

Action plan
Convert the selected guideline specifications into performance measures. This is precise work that requires development of the “numerator” and “denominator” populations that most closely match those described in the guideline. It requires codification of complex logic and includes time-specific application of recommended procedures.

Build an analytically ready database
To accomplish this, gather the necessary data sets for creating these measures, clean the data to ensure that they are reliable and will generate valid measures, and standardize the data so that they are properly configured. Start with simple measures and move along the continuum to more complex measures. Recognize that data sources and data management issues also become more complex along the continuum.

Link this analytically ready database to the reporting application
An iterative approach is required to test and refine measures to ensure that final results are actionable and accurately reflect the underlying guideline. Without accuracy, EBM loses credibility; without actionability, the results provide interesting statistics without a roadmap for improvement. Decision support systems and reporting applications that organize the data and generate the performance

measures are available and can be purchased externally or, fr the truly ambitious, developed in-house. This requires the biggest investment of time and money. That’s why it’s critical to take advantage of work done by others. Externally available systems incorporate years’ worth of experience and knowledge, and provide the means to quickly and successfully begin using EBM to improve and demonstrate quality of care.

Success story
Using a retrospective claims-based decision support tool and in-house lab and pharmacy automated tools, Valley View Hospital, an 80-bed acute care hospital in Glenwood Springs, CO, identified community-acquired pneumonia as one of its top-volume conditions and one with variation in cost, use and quality performance. Practice guidelines that provided clear linkage between the clinical process measures and favorable outcomes were used as reference for building patient care pathways for Valley View’s emergency and inpatient care processes. Specific measures developed from the guidelines included total charges, average length of stay, time to initial antibiotic administration, sputum sample before antibiotic administration, and unplanned readmissions.

The program began in 1996 and target performance rates were developed based on the following baseline:

• Total charges should range from $4,200 to $6,000 per case.
• Average length of stay (ALOS) should be less than four days.
• Time to initial antibiotic should be less than 120 minutes after arrival.
• Sputum sample before antibiotics should be collected at least 80 percent of the time.
• Number of patients with unplanned readmissions should decrease by at least 10 per cent.

Performance was measured and results shared routinely with the medical staff. Through implementation of the evidenced-based medicine clinical pathway, most recent results for these measures were:

• Charges averaged $5,400 per case.
• ALOS averaged 3.6 days.
• Time to antibiotic averaged 80 minutes.
• Sputum collection averaged 93 per cent.
• Unplanned readmissions within 30 days decreased by 36 per cent.

Valley View hit all its benchmarks. In fact, Valley View’s success with its first effort was so significant; the evidence-based medicine approach has since been applied to 20 other disease conditions and has resulted in similar measurable improvements.

Scenario in India
Success stories as in Valley View can be replicated in India too. However this requires a paradigm shift in the mindset, fundamentally in terms of viewing healthcare as a business as compared to charity. Though medical care has made major progress in India, healthcare administration in both private and public sector has a long way to go. The advent of professional managers and the opening up of the insurance industry have placed the industry at a critical juncture. It is time for the professional medical organizations such as IMA to take a proactive role in bringing out consensus-based guidelines for treatment of disease, which are specific to the conditions prevalent in India. This would involve a substantial investment in time and money. In the fast changing healthcare scenario, I guess the move for EBM will catch on, the driver for change being the insurance industry. The downside to this is however, is overenthusiastic insurance companies transplanting practices which would have been successful in other countries. The time is come for healthcare professionals and healthcare management professionals to work in tandem to address this, and a host of other issue in the healthcare landscape.

(The author is MD, MBA, working with Silverline Technologies, New Jersey and can be contacted at saji.salam@silverline.com)