Failing To Keep Pace And Only Falling Further Behind

In 1970, there were about 200,000 published peer-reviewed medical articles. That number has exploded to more than 800,000 in 2010. We can only wonder how many other life-saving interventions are hidden in that body of work. 

If a simple, life-saving medical intervention was discovered and subsequently proven effective by seven randomized controlled trials (RCTs), you might expect that the procedure would gain immediate support from physicians. In fact, in 1972 the use of a short, inexpensive course of corticosteroid given to women in premature labor was shown to dramatically reduce the risk of newborns dying from the complications of immaturity. By 1991, seven more RCTs reinforced these results, showing that corticosteroids reduced the odds of infant death by 30% to 50%. But because no systematic review of these trials was published until 1989, most obstetricians simply didn’t know the treatment was so effective. In the interim, tens of thousands of premature babies suffered and died unnecessarily.1

This isn’t an isolated incident.

In 1970, there were about 200,000 published peer-reviewed medical articles. That number has exploded to more than 800,000 in 2010.2 We can only wonder how many other life-saving interventions are hidden in that body of work.

In my previous post, I wrote about the length of time it takes for evidence-based treatment to reach the point of care—an average of 17 years. These statistics show how critical it is that we review bodies of literature to more quickly find patterns and make decisions that can positively impact patient care.

But beyond literature review, there are other obstacles in our path from a published study or clinical guideline to matching that to an individual patient.

How do you apply new guidelines to your population without an effective blueprint? How do you get those guidelines codified into your IT systems and then train all the members of your provider team on how to consistently implement them? How does the guideline apply to different populations? Are there valid reasons to override the guideline for a specific patient? How should you negotiate with each patient in a shared care plan?

Even once you’ve pushed a guideline throughout your organization, the trick is to make sure the implementation doesn’t break down somewhere along the way. In our experience, even large, highly respected healthcare systems with exceptional expertise in specific areas can see break-downs in the implementation of basic guidelines such as vaccinations. The fact is, it can take years for new guidelines to become ingrained across an organization.

Part of that is human nature and part is systemic. For instance, we consistently hear from care organizations that they’re frustrated by the backlog of IT projects, many of which are required system upgrades that have nothing to do with implementing the latest medical evidence. For many organizations, the fallback is to communicate new guidelines via email. Imagine if new airline safety standards were emailed to pilots, with the assumption that those standards would immediately be consistently and appropriately implemented on every flight.

Clearly that’s not enough. We have to get these guidelines codified into software at the point of care. But that doesn’t mean taking us back to the argument of “cookbook medicine.” It’s recognizing that no single provider can keep up with the explosion of new information. It’s allowing a physician’s staff to manage standing orders based on clinical evidence so that every member in the care team works at the top of their licensure. It’s ensuring that physicians can focus their limited time in applying their expertise to each individual patient’s needs and deciding on the most effective variations.

So how do we get from here to there?

We’ve issued a challenge to reliably translate evidence into practice within 90 days of publication. When we state this challenge, rooms tend to get very quiet in response. Yes, it’s hard to keep up. Yes, evidence

keeps changing. But without a specific goal and an identified timeline, nothing will change. In the same way that we adjust our investment portfolios even as stocks go up and down and markets change, we need to adapt more effectively to new evidence-based guidelines. The tools exist. It’s time to take on the challenge.

1 Crowley P. Prophylactic corticosteroids for preterm birth. The Cochrane Database of Systematic

Reviews 1996, Issue 1. Art. No.: CD000065. DOI: 10.1002/14651858.CD000065.

2 Miliard, M (2015, July 14). Clinical decision support: no longer just a nice-to-have. Healthcare IT News:

http://www.healthcareitnews.com/news/clinical-decision-support-no-longer-just-nice-have.

J. Siemienczuk, MD