Evidence-based medicine has been receiving a lot of attention of late and for good reason. Our healthcare costs have spiraled to new levels consistent with more sophisticated technologies, newer drugs, and increased utilization. In seeking to reign in costs and manage the free-for-all that has ensued, our administration plans to implement substantial changes.
Among the broad changes seen as necessary to control cost growth within our healthcare system is the modification of payment systems to encourage more appropriate use of resources and reward providers who deliver care that adheres to evidence-based guidelines. The overriding goal is to improve efficiencies and one of the sources of inefficiency cited is a payment system that rewards medical input, rather than outcomes. By systematically evaluating which treatments are the most effective, universal performance measures can be developed. Toward this end, having spent the past few decades collecting and analyzing outcomes data, both Congress and the Centers for Medicaid & Medicare Services (CMS) have committed unprecedented resources to enforcing evidence-based coverage policies. CMS seeks to develop Medicares reimbursement structure around evidence-based outcomes and this has brought the RAC audits program to the forefront for every provider of Medicare services. The target is overpayments, the objective is lightening the load on a strained national budget, and one of the effects of these efforts will be reducing Medicare fraud.
Variation
Presently, our healthcare system reflects extensive variation in the quality of care provided to patients. Rather than dictating the type of care that should be provided, applying best practices is about providing patients and doctors with the information they need, when they need it, in a form that can be easily understood. Incorporating best practices, evidence-based medicine (EBM) consists of using current, best available clinical evidence to make decisions about individual patient care. The objective of this system is to reduce emphasis on unsystematic clinical experience and promote the examination of evidence from clinical research. Through the integration of clinical expertise, patient values, and evidence derived from systematic research, it is believed optimal clinical outcomes and improved quality of life can be achieved.
In the US, there are few coordinated efforts to objectively quantify the benefits of new devices, drugs, and procedures for diagnosing and treating diseases. It is also difficult for providers to keep up with the best available evidence regarding clinical risks and potential health benefits of alternative treatments. This lack of information likely explains, at least in part, the variation in treatment patterns and the escalated spending that has resulted in marginal objective value. Similarly, there are few information resources for consumers. And this has lead to consumers inability to make informed decisions when selecting providers and treatments.
Applying EBM
The process of applying EBM typically begins with a clinical question. The structure of the question consists of (1) the particular patient or problem, (2) the intervention (or treatment), (3) a comparison, if necessary (perhaps other kinds of medications or tests), and (4) the outcome, which is the desired goal of the treatment or improvement sought. Once the question is clarified, a systematic retrieval compiles the best medical evidence available. The evidence must then be critically appraised, which typically involves the use of various statistical tools and calculations. Following this, a decision is made. Ultimately, the performance is evaluated and this entails reflecting on the learning process. It is the integration of relevant evidence with clinical experience that forms the cornerstone of evidence-based practice.
Opponents have expressed concern that EBM takes the results of large studies groups and attempts to apply them to the individual, thereby overshadowing the unique circumstances or characteristics not reflected in the study groups. It is important to recognize, however, that EBM should not be relied upon in a vacuum, and that it is up to the physician to determine whether the data and results are applicable to the individual patient Clinical expertise and current best evidence are dependent upon one another and there are different sets of risks associated with practicing one to the exclusion of the other.
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