Category Archives: Evidence-based requirements

The scientific method?

Look for this interesting article in the upcoming weekend’s New York Times Magazine. The article looks at the progress of evidence-based medicine, the attempt to minimize variation in care, and specifically at Dr. Brent James from Intermountain Healthcare in Utah and Idaho. Here’s an excerpt (citing Dr. John Wennberg of the Dartmouth Atlas):

Wennberg, the Dartmouth researcher, argues that Intermountain is fundamentally different from other oft-cited models of high-quality, lower-cost care, like the Mayo Clinic and the Cleveland Clinic. These places, including Intermountain, share certain traits, like having a large number of doctors who receive fixed salaries rather than being paid piecemeal for each treatment. Partly as a result, these hospitals do fewer tests, treatments and operations than other hospitals and still get excellent results. What sets Intermountain apart, Wennberg says, is that it is also making a rigorous effort to analyze and improve bedside care.

“It’s the best model in the country of how you can actually change health care,” Wennberg told me. I heard nearly the same argument from Anthony Staines, a health scholar and hospital regulator in Switzerland who recently completed a study of some of the world’s most-admired hospitals. “Intermountain was really the only system where there was evidence of improvement in a majority of departments,” Staines said.

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Where do clinical guidelines fit in the medmal fix?

What follows is excerpted from a recent healthcare reform briefing paper by Chad Karls, “Retooling Medical Professional Liability”

Clinical guidelines are not a new idea, but the idea of using them to shield doctors from malpractice lawsuits has gained some purchase of late. The idea is to establish a list of agreed-upon, evidence-based guidelines, which, if followed, would give physicians and other healthcare providers safe harbor from claims of malpractice. In addition, if physicians are in fact protected from medical negligence lawsuits provided they follow such guidelines, this could have an additional and significant benefit of reducing the level of defensive medicine that takes place.

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Barriers to the adoption of clinical decision support tools

What follows is excerpted from “The convergence of quality and efficiency,” by Helen Blumen and Lynn Nemiccolo. Today’s discussion continues where yesterday left off, explaining resistance to the convergence concept.

One of the major barriers identified in the NEJM study was physician resistance. In the hospitals surveyed, 36% of those who did not have an EHR stated that physician resistance was a barrier.34 Physicians resist the use of CDS tools for a variety of reasons, but the main reason is the belief that the use of an EHR and CDS tools will decrease clinical productivity and affect financial reimbursement. Other reasons range from not wanting a computer system to infringe on their decision making to something known as alert fatigue. Alert fatigue is when physicians have been exposed to poorly implemented EHRs that warn them continuously of possible problems as they access the system. Moreover, many of the CDS tools used today have been developed without clinician input, increasing resistance to their use. But if guidelines can be used to fine-tune EHR, and EHR can inform the creation of more user-efficient guidelines, what can emerge is a usability feedback loop that results in a self-improving system that avoids the dynamic of alert fatigue.

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Resistance to best-practice guidelines

What follows is excerpted from “The convergence of quality and efficiency,” by Helen Blumen and Lynn Nemiccolo.


Unfortunately, even when guidelines score well using the AGREE instrument, providers may still view them negatively. One example of this is an examination of guidelines conducted by researchers at RAND. One of the questions within the AGREE rigor-of-development domain requires that experts in both clinical content and guideline methodology who are external to the organization that has developed the guidelines review them, but it does not provide detailed specifications for the review. RAND researchers examined a set of guidelines for common, expensive diagnostic testing and treatment for musculoskeletal disorders of the spine and extremities. The researchers gave these guidelines high scores using the AGREE instrument. Then they asked a panel of providers (recommended by their specialty societies as leaders in their clinical field) to rate the relevance of the guidelines to common clinical situations and consistency with clinical understanding of existing evidence and expert opinion. The expert panelists thought that the guidelines did not address common clinical situations, and reported that they often disagreed with the experts’ interpretation of published evidence and clinical experience. In the face of findings of this nature, it is not surprising that guideline adherence in real-world situations may be imperfect, or that implementation of guidelines in healthcare systems may be met with resistance.

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Setting standards for the standards

What follows is excerpted from “The convergence of quality and efficiency.” Click here to read the full paper or view citations.


The Appraisal of Guidelines Research & Evaluation (AGREE) instrument consists of 23 items organized into six domains, each of which captures a separate dimension of guideline quality. The domains are scope and purpose, stakeholder involvement, rigor of development, clarity and presentation, applicability, and editorial independence.

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Appropriate care leads to better outcomes

What follows is excerpted from “The convergence of quality and efficiency,” by clinicians Helen Blumen and Lynn Nemiccolo. 


In contrast to how inappropriate care often leads to worse healthcare outcomes, there is evidence that appropriate healthcare leads to better outcomes. An examination of the use of tonsillectomy is a good example of the positive relationship between appropriateness and efficacy. Tonsillectomy is the most common surgical procedure performed in children, and a randomized, controlled trial has demonstrated its efficacy in decreasing the incidence of throat infection. These results justify the choice of tonsillectomy for children who met the very stringent eligibility criteria of clinical trials.


A subsequent clinical trial, conducted by the same researchers, considered children who were less severely affected by throat infections. This study found that both the control and surgical groups had relatively low rates of severe infection. And of those children treated surgically, nearly 8% had complications.

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