SLC CME- Evidence based medicine 07/27/2007
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SLC CME- Evidence based medicine 07/27/2007

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Saint Luke's Care, a quality improvement organization within Saint Luke's Health System, presents a CME presentation by Dr. Brent Beasley on Evidence Based Medical Care.

Saint Luke's Care, a quality improvement organization within Saint Luke's Health System, presents a CME presentation by Dr. Brent Beasley on Evidence Based Medical Care.

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SLC CME- Evidence based medicine 07/27/2007 SLC CME- Evidence based medicine 07/27/2007 Presentation Transcript

  • Evidence-based Medicine: from the Laptop to the Bedside Brent W. Beasley, MD, FACP Program Director, Internal Medicine Residency University of Missouri—Kansas City Medical 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…
  • Problem
    • She could:
    • Consult a pulmonologist—they’ll do the best job.
    • Do what she usually does. Start writing orders and hope she gets it correct.
    • Do a comprehensive Medline literature search on the computer in the office and try to figure out the right approach.
    • 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):977-87 Whittle 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):977-87 Whittle 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)
  • Problem
    • She could:
    • Consult a pulmonologist—they’ll do the best job.
    • Do what she usually does. Start writing orders and hope she gets it correct.
    • Do a comprehensive Medline literature search on the computer in the office and try to figure out the right approach.
    • 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. Links Switzer GE , Halm EA , Chang CC , Mittman BS , Walsh MB , Fine MJ .
  • Problem
    • She could:
    • Consult a pulmonologist—they’ll do the best job.
    • Do what she usually does. Start writing orders and hope she gets it correct.
    • Do a comprehensive Medline literature search on the computer in the office and try to figure out the right approach.
    • None of the above?
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  • All Roads Lead to Rome!!!
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  • 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 Policy
    • Evidence 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 Policy
    • Values 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 Policy
    • Grading 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 Policy
    • Updating
    • 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?
    • Between RVUs and patients waiting, family demands, and waiting messages…
  • Problem
    • She could:
    • Consult a pulmonologist—they’ll do the best job.
    • Do what she usually does. Start writing orders and hope she gets it correct.
    • Do a comprehensive Medline literature search on the computer in the office and try to figure out the right approach.
    • 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 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 CAP management guidelines be locally adapted and 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 elements 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 outcomes . (Moderate recommendation; level III evidence.)”
    IDSA/ATS Consensus Guidelines on the Management of CAP in Adults Mandell, et al. Clinical Infectious Diseases    2007;44:S27-S72
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  • 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.
  • Measure
  • 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
    • 2 nd 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 Practice Team Product: ACS Orders
  • St. Luke’s Care Cardiology Evidence-based Practice Team Product: ACS Orders
  • Complete Post-Test for credit
    • Please click to enter your post presentation questions for CME credit
  • Post-Test Questions
    • 1. After reviewing this CME presentation, how likely are you to use preprinted ordersets sets for appropriately selected patients in the future? (circle one)
    • Highly Unlikely No more nor less likely Highly Likely
    • 1 2 3 4 5
    • 2. National Guidelines for the management of pneumonia have strongly recommended the use of locally implemented Clinical Practice Guidelines and Pathways. (circle one)
    • True False
    • 3. Higher hospital volume has been associated with:
      • a. Improved outcomes in medical and surgical patients.
      • b. Improved outcomes in medical patients and worse outcomes in surgical patients.
      • c. Worse outcomes in medical patients and improved outcomes in surgical patients.
      • d. Worse outcomes in medical patients and surgical patients.