By Tiffany Lauria
Two recently released reports have brought to light an interesting point regarding evidence based medicine- that it may not be as widely used as thought, or should be.
In a retrospective cohort study of cases submitted to the National Cardiovascular Data Registry-ICD Registry between January 1, 2006, and June 30, 2009, researchers found that out of 111,707 patients, 25,145 received implantable cardioverter-defibrillators (ICDs) that were not recommended by evidence-based guidelines. In other news, a study published in Arthritis Care & Research highlights that physicians treating patients with osteoarthritis (OA) may not be adhering to the recommended guidelines and that clinical practice often diverges from the medical evidence.
So why the big deal? Simply put, evidence-based medicine works, and not adhering to it on a routine basis puts patients at risk and continues to add increased costs to our already over-burdened system. The patients who had non-evidence based ICDs in the above referenced study experienced a 0.57% risk of in-hospital death, compared to 0.18% in the patients who received an implant following standard approved guidelines. The same group also had an increased risk of post-procedure complications. How does a physician go about explaining this situation to the family of a patient that passed away, despite having clear guidelines to follow?
Ultimately, our healthcare boils down to trusting in our provider’s clinical expertise. Granted, the clinical experience of our provider is often comprehensive and trustworthy- caring for thousands of patients with the same problems over the years, does tend to make one qualified to judge what works and what doesn’t. However, clinical expertise is largely dependent on staying abreast of new techniques and updated guidelines. It requires that providers know what works and what doesn’t in the national and international population, not just in their patient base over their years of practice. And, while each of us personally may be comfortable with our physician’s clinical judgment, regardless of what the evidence suggests, it is undoubtedly dependent on the provider to justify any decision-making that varies from evidence-based proof.
I certainly don’t make the statement that EBM is in-fallible, or that in all cases it is the right way to go. It is possible to mis-use or over-use the guidelines to the patient’s detriment. Blindly following a ‘proved’ algorithm of care eliminates the very essence of personalized healthcare. All patients are entitled to care that considers the patient as a whole. The EBM guidelines for two different conditions may cancel each other out, or worse yet, do more damage than good. And the personal opinions and circumstances of your patients must be considered. After all, what good is evidence when it can’t (or won’t) be followed? So where clinician training, experience and judgment dovetail with the evidence is where you want your medical practice to be. Without this quadrant of care, the potential for good medicine is lacking.
We can look, however, to the mentioned studies for some ideas on why physicians may be thwarting the evidence. For example, in the ICD study, the number of non-evidence based implants was significantly different according to physician specialty and hospital. Therefore, it is reasonable to conclude that the practicing environment and specialty culture may have a large impact on a provider’s commitment to adhering to recognized guidelines. In addition, the extent in which a facility appropriately enables provider staff to maintain up-to-date knowledge of evidence-based guidelines, by the provision of educational and other resources, is likely to be largely diverse across organizations. As the old saying goes- he that is walking with wise ones, becomes wise. If providers surround themselves with an environment conducive to learning and a culture of evidence-based decision making, then using proven treatment guidelines will become their standard of care. Supplemented, of course, by their years of trusted judgment based on clinical experience in the patient arena.
As medical evidence increasingly becomes more accessible to the general population, providers will have additional reasons for ensuring that their clinical practice remains within the close confines of what has been proven and substantiated. With the advent of the internet, construction worker John Smith need only go to any number of medically oriented websites or patient forums to determine what tests and treatments are routinely prescribed and what is the ‘norm’ for a particular illness or condition. A particularly savvy patient, with persistent researching skills, may ultimately wind up uncovering the specifics of the national guidelines that pertain to their condition…and bring that in to face you, the provider, who may be doing otherwise.
Certainly, no one is advocating for cookie cutter medicine or a one-size-fits-all approach to healthcare. Clinical experience and a provider that is willing to step out of the box in their effort to best treat their patients are more than needed in today’s climate of increasingly complex conditions and new advances. However, the question of why evidence-based medicine is not common practice yet needs to be addressed by providers, facilities and regulators in order to determine the best means of integrating proven care strategies into everyday care. It shouldn’t take a health reform initiative to convince people that making decisions based on evidence, just plain works.
 David J. Hunter, Tuhina Neogi, and Marc C. Hochberg. “Quality of Osteoarthritis Management and the Need for Reform in the US.” Arthritis Care and Research; Published Online: June 25, 2010 (DOI: 10.1002/acr.20278); Print Issue Date: January 2011. http://onlinelibrary.wiley.com/doi/10.1002/acr.20278/abstract