The Journal for Nurse Practitioners
Volume 8, Issue 1 , Pages 51-55, January 2012

Making Evidence-based Health Care Relevant for Patients

  • Jill Muhrer, FNP-C

      Affiliations

    • Jill Muhrer, MSN, FNP-C, practices as an adult nurse practitioner at CAMcare Health Corporation in Camden, NJ, and an adjunct clinical instructor at Widener University in Chester, PA. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest.

Article Outline

Abstract 

Evidence-based health care provides clinicians with the scientific data necessary to provide high-quality care to patients with specific diseases, while pay-for-performance initiatives reward clinicians for adhering to performance guidelines in managing these diseases. Although these guidelines provide the best treatment for a given disease, they don't necessarily determine the optimal treatment for individuals because they don't address patients with comorbidities, nor do they consider patient preferences. In order to improve outcomes, clinicians and patients should collaborate to formulate a treatment plan that incorporates both evidence-based data and patient preferences within the context of each patient's specific clinical situation.

Keywords:  clinical practice guidelines , evidence-based health care , motivational interviewing , patient-centered care , pay for performance , payoff time

 

Since the early 1990s, evidence-based health care (EBHC) has rapidly become the most widely accepted approach to clinical practice.1 EBHC can be summarized as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical experience with the best available external clinical evidence from systematic research.”2 In 2000, this definition expanded to include the values and preferences of the individual patient.3, 4

EBHC has become a highly-refined science that provides clinicians with the quality of information they require to make complex clinical decisions regarding the best-recommended practice for patients with specific diseases.1 In many cases the benefits of using evidence-based information are clear, such as with the increased use of beta-blockers for patients with acute myocardial infarctions.1

However, an approach focused primarily on this type of evidence does not always translate into better outcomes for patients.1 For example, despite the excellent evidence-based information regarding the management of hypertension, studies show that half of hypertensive patients still have uncontrolled hypertension.1 One possible reason for these poor outcomes is that EBHC doesn't always take into account the real-life obstacles that patients face in trying to follow these recommendations.1 Therefore, in addition to reviewing the scientific evidence, it is important to consider patients' social circumstances, cultural backgrounds, and preferences.4

One method to incorporate patients' preferences into EBHC is through patient-centered care (PCC), which focuses on patients' experiences rather than their diseases and encourages patients to actively participate in decision-making.4, 5 In this approach, clinical judgment involves integrating guidelines into relevant clinical practice that incorporates the socioeconomic needs and cultural traditions of patients and their personal preferences.4, 5 Primary care practitioners in general and nurse practitioners (NPs) in particular are the perfect candidates to help patients review these issues and to ultimately determine the relevance of EBHC to their specific needs. Since nursing education emphasizes patient communication, NPs are already adept at the skills required for PCC and are therefore highly qualified to take a leadership role in implementing that care.4

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Challenges 

Insurance Isssue 

One potential obstacle to the integration of patients' preferences into EBHC is its use as a scientific basis to develop health care policies, such as insurers' decisions regarding coverage.6 Undoubtedly, one area that affects clinical practice the most is the pay-for-performance (PFP) movement, which uses clinical practice guidelines (CPGs) as quality measures to assess clinical performance and to then determine payment.6, 7, 8 Clinical practice guidelines are systematically researched recommendations developed to help clinicians and their patients determine how best to manage specific conditions.5, 7

The goals of PFP financial incentives are to use CPGs to standardize and improve quality of care, reduce health care costs, and offer both patients and payers an objective method of comparing the quality of care provided by various providers.6, 7, 8 In an effort to achieve these goals, a growing number of insurers are moving away from traditional fee-for-service reimbursement and are adopting PFP payment plans.5, 8 As a result, clinicians are often evaluated and then reimbursed according to their use of CPGs, which could discourage them from caring for more complicated and less compliant patients.5, 8 Ultimately, this pressure to follow standardized CPGs could also make it more difficult to adjust EBHC to patients' preferences.

Patients With Multiple Diseases 

The growth of PFP initiatives rewards clinicians for adhering to CPGs for the management of single diseases.9 The goal is to provide optimal care, often including multidrug regimens, to treat patients with that particular disease.9 The problem is that most patients don't have single diseases, and the majority of CPGs don't address the complexity of dealing with patients who have multiple illnesses.9 According to a recent survey, approximately 75 million people in the United States have multiple (2 or more) concurrent chronic conditions,10, 11 and among the elderly, at least 20% of Medicare patients have 5 or more chronic conditions, with 50% receiving 5 or more medications.12, 13

Despite the high incidence of patients who have several illnesses, a recent analysis of CPGs for 9 of the 15 most common chronic illnesses noted that only 4—diabetes mellitus, osteoarthritis, atrial fibrillation, and angina—included recommendations for adjusting CPGs for patients with multiple comorbidities.7 The majority of these CPGs addressed patients with only 1 disease or a cluster of related conditions.7

When clinicians apply single disease-oriented CPGs to patients with multiple diseases, they can inadvertently place these patients at risk for polypharmacy, with a higher incidence of adverse reactions.7 In one example, applying 5 disease-specific CPGs to a 79-year-old woman with hypertension, diabetes mellitus, chronic obstructive pulmonary disease, and osteoporosis would result in her taking 12 separate medications with a total of 19 doses per day given 5 times during a typical day.7 The resultant combination of drugs could easily cause unintended side effects, negative drug interactions, and additional harmful drug effects when medications used for one condition have a negative impact on another.7, 9

These unintended side effects can be further compounded when common over-the-counter medications for such conditions as allergies, pain, dyspepsia, and insomnia are combined with prescription medicines.9 Therefore, while CPGs may provide information about the best treatment for a given disease, they don't necessarily determine the optimal treatment for the individual patient.9

In addition to causing unintended medication side effects, complex treatment programs can also interfere with patients' daily routines, interrupt social activities, and lead to nonadherance.14, 15, 16 Furthermore, medications costs can easily exceed $5,000 per year, and this can be compounded by the additional cost of multiple office visits.7, 9 To complicate matters even more, elderly patients often have a higher incidence of complications, an inability to tolerate or afford multiple medications and lifestyle interventions, and, with their limited life expectancy, may not be the best candidates for certain treatments.7, 14

While many clinicians are aware of the need to adjust CPGs to individuals, the majority of PFPs don't reward providers for taking care of patients with multiple illnesses, nor do they address the complexity of coordinating care for these patients.7, 8, 14 Furthermore, they may inadvertently discourage practitioners from caring for these patients by threatening their quality rankings and, consequently, their rates of reimbursement7, 8, 14 This can easily occur when PFPs narrowly focus on single disease guidelines and then use multiple single disease-focused quality indicators to judge the care provided to patients with comorbidities7, 14 Clinicians who care for complicated patients would be less likely than those who care for patients with only 1 disease to score high on quality evaluations, which ultimately threatens their rates of reimbursement.7, 14 The end result could be that the patients who have the greatest health care needs may be the least likely to find care.

Research Used to Guide EBHC 

One additional factor to consider when evaluating the relevance of EBHC to a particular patient is to determine whether the findings can be generalized to patients outside of the research setting.6 A health care intervention that is considered beneficial in a research setting may not offer the same benefits for patients in a real-life office setting.6 Therefore, an intervention must be considered within the context that it will be used to determine its effectiveness for specific patients.

One example of the need to match guidelines to individual patients is determining their relevance to patients with comorbidities who may not live long enough to benefit from the intervention and who may even be harmed by it.17 In a study of 600,000 veterans, 33% of patients older than 85 were screened for prostate cancer, even though most of them were unlikely to survive long enough for the benefits of screening to exceed the harms.18 In a similar analysis, when patients with multiple chronic illnesses were diagnosed with early-stage colorectal cancer through cancer screening, many had 3 or more cormorbidities and did not survive long enough to benefit from the early diagnosis.17, 19

One solution would be to use a payoff time calculation to adjust CPGs to patient comorbidity profiles.17 A payoff time is defined as “the minimum elapsed time until the cumulative incremental benefits of a guideline exceed its cumulative incremental harms.”17 If the payoff time of a CPG exceeds the patient's life expectancy, the guideline would be modified because it probably wouldn't offer any benefit. For instance, a 60-year-old man with diabetes, congestive heart failure, lung disease, and stroke wouldn't qualify for colorectal screening, which has a payoff time of 7.3 years, because his projected life expectancy would only be about 3.7 years.20 The goal of calculating payoff times is to customize guidelines to meet the realistic needs of the individual.

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Quality Concerns 

One important question to consider is whether or not strictly adhering to CPGs compromises quality of care. In a recent study, researchers looked at this question by developing a computerized clinical decision-support system that enabled practitioners to record their reasons for not following CPGs.21 They determined that practitioners' justifications for not complying were usually valid and concluded that, by offering providers the opportunity to record these reasons, they could more effectively adjust care to patients' needs.21 Furthermore, this adjustment would improve both quality of care and performance. However, in order to be efficient, documenting exceptions would need to be integrated into the expected time frame of an office visit.21

Recently, a report in the Annals of Internal Medicine aimed at evaluating the effects of individualized guidelines on quality of care demonstrated that the use of more personalized guidelines could not only improve care but also reduce costs.22 Using person-specific longitudinal data on participants from the Atherosclerosis Risk in Communities Study who did not have cardiovascular disease and had not received antihypertensive treatment, researchers compared the treatment outcomes of patients managed with random care, guideline specific care, or individualized guidelines.22 In their 12-year follow-up analysis comparing the rate of myocardial infarctions and strokes in this population, they discovered that patients who had received standard care had 43% more strokes or heart attacks than those treated according to a tailored guideline.22 Furthermore, the use of personalized guidelines reduced the cost of care by 67%.22

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Clinical Judgment Reconsidered: Evidence in Context 

Patients' Preferences 

In addition to reviewing illness factors in tailoring treatment, eliciting patients' preferences is critical to providing relevant care. As patients are encouraged to take a more active role in decision-making, it is the provider's responsibility to determine patients' values, help them find the best information, and then support them in the decision-making process.5 Despite this call for increased patient involvement, when researchers with the American Institutes for Research in Washington, DC, surveyed more than 1,700 health care consumers through focus groups, interviews, and an online survey, they found that only 1 in 3 patients said a clinician had discussed evidence-based research with them.23

Furthermore, only 34% of patients said their providers had ever reviewed research results with them about how to manage their care, and 41% of respondents didn't ask questions because they weren't sure how to communicate with their providers or because they felt rushed.23 Many admitted to confusion about the terms medical evidence, quality guidelines, and quality standards.23 These misconceptions, along with patients' hesitancy to share their concerns, further complicate the challenges that providers face in eliciting patients' values.23

While this lack of communication may be true for most clinicians, there is solid evidence that NPs provide more education and counseling services than physicians.24 In a literature search regarding NPs' contributions to primary care, the researchers determined that NPs provided longer consultation times to patients, which translated into improved patient satisfaction.24 In addition, there were no differences in outcomes, such as mortality and physical, emotional, and social functioning of patients seen by NPs compared to physicians.24

Some NPs are using motivational interviewing (MI) to improve communication.25 MI is an interview style that encourages patients to share their beliefs openly in a nonjudgmental environment, and it focuses primarily on determining their goals.25, 26 This method places patients in a collaborative role with their providers because they are also viewed as experts.26 In an article regarding an NP perspective on the use of MI for improving cardiovascular health, Van Nes and Sawatzky conducted a comprehensive overview of MI and demonstrated how its use could reduce cardiovascular complications.25 They concluded, “MI is an appropriate, evidence-based strategy to promote cardiovascular health” and added that MI can be efficiently integrated into a brief patient encounter.25

In another study where MI was used to elicit patients' personal goals regarding weight loss, patients who experienced MI lost 3.5 pounds more than those who went through a nonmotivational talk that included confronting, persuading, and offering advice without tapping the patient's input.26 Therefore, approaching patients with an interview style that accesses their values in a non-biased manner not only elicits more information on their preferences but also leads to improved adherence and better clinical outcomes.26

Unfortunately, even when clinicians are able to successfully elicit patients' preferences, there is no guarantee that researchers responsible for creating CPGs will take them into account. An estimated 25% of guideline developers include patients in the development process.27 Furthermore, in an analysis of 51 CPGs, only 5% of the word count and 6% of references in the guidelines related to patient preferences.28 In another study regarding the management of atrial fibrillation, large gaps were noted between the best choices for individuals when their values were included in the decision analysis versus the treatments advocated by CPGs.29 This lack of attention to patient goals represents a major flaw in translating CPGs into effective treatments for individuals.

In order to increase patient roles in the development of CPGs, some experts recommend researching preference-related evidence.5 This would include studies of quality of life measures, qualitative reviews of patient experiences, analysis of patient decisions, and studies of social values.5 Including preference-related evidence into CPGs would acknowledge patients' importance in determining relevant treatment strategies.5

Treatment Tailoring and the Therapeutic Alliance 

The integration of patients' values with guidelines requires a relationship between patients and clinicians that is based on solid communication and mutual respect. Effective communication can move a relationship that is clinician-dominated and often paternalistic to one that is relationship-centered.30

In a recent article, Epstein et al30 recommend 5 steps that clinicians can use to improve communication. These steps include understanding patients' experiences and expectations; building a partnership; providing evidence, including a review of uncertainties; presenting recommendations adjusted by evidence and patients' preferences; and then checking with patients to see if they understand and agree with the recommendations.30 In addition, communication should be sensitive to patients' cultural and ethnic backgrounds, reflect their health literacy levels, and include a translator if indicated to overcome language barriers.4 Through successful communication, clinicians and patients can determine a relevant treatment strategy.

Some clinicians now recommend that, in order to truly understand patients' personal circumstances, they need to extend clinical care beyond the office and into the community.1 In a perspectives article, Moskowitz and Bodenehimer recommend implementing an evidence-based health model that would address patients' needs directly in their home through community health services.1 This plan would enable clinicians to take into account patients' real-life circumstances while focusing on encouraging them to take an active role in managing their illnesses.1

EBHC has evolved into a refined science that provides high-quality, evidence-based data to clinicians.1 This has greatly enhanced the quality of data that providers have available to them when making informed decisions about best treatment options for patients.1 Patients, on the other hand, offer another form of expertise since they know best what their own goals, preferences, and real-life situations involve.

Through the formation of a therapeutic alliance, clinicians and their patients can customize decisions to include the best scientific evidence all within the context of individuals, which ultimately should translate into improved patient outcomes. NPs are highly skilled in communicating, counseling, and educating patients and therefore are poised to take a leadership role in continuing to make EBHC relevant to their patients.

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References 

  1. Moskowitz D , Bodenheimer T . Moving from evidence-based medicine to evidence-based health . http://www.springerlink.com/content/u3707228u858604p/fulltext.html Accessed March 16, 2011.
  2. Sackett D , Rosenberg W , Gray J , et al.   Evidence based medicine: what it is and what it isn't . Br Med J . 1996;312(7023):71–72
  3. Guyatt G , Haynes R , Jaeschke R , et al.   Users' guides to the Medical Literature: XXV: evidence-based medicine: principles for applying the Users' Guides to patient care: Evidence-Based Working Group . JAMA . 2000;284(10):1290–1296
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  9. Tinetti M , Bogardus S , Agostini J , et al.   Pitfalls of disease-specific guidelines for patients with multiple conditions . N Eng J Med . 2004;351(27):2870–2876
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  16. Johnson P , Veazie P , Kochevar I , et al.   Understanding variation in chronic disease outcomes . Health Care Manag Sci . 2002;5:175–189
  17. Braithwaite S , Concato J , Chang C , et al.   A framework for tailoring clinical guidelines to comorbidity at the point of care . Arch Intern Med . 2007;167(21):2361–2365
  18. Lee S , Lindquist K , Segal M , et al.   Development and validation of prognostic index for 4-year mortality in older adults . JAMA . 2006;295(7):801–808
  19. Gross C , McAvay G , Krumholtz H , et al.   The effect of age and chronic illness on life expectancy after a diagnosis of colorectal cancer: implications for screening . Ann Intern Med . 2006;145(9):646–653
  20. Braithwaite R , Fiellin D , Justice A . The payoff time: a flexible framework to help clinicians decide when patients with comorbid disease are not likely to benefit from practice guidelines . Med Care . 2009;47:610–617
  21. Persell S , Dolan N , Friesema E , et al.   Frequency of inappropriate medical exceptions to quality measures . Ann Intern Med . 2010;152:225–231
  22. Eddy D , Adler J , Patterson B , et al.   Individualized guidelines: the potential for increasing quality and reducing costs . Ann Intern Med . 2011;154:627–634
  23. Carman K , Maurer M , Mathews J , et al.   Evidence that consumers are skeptical about evidence-based health care . Health Affairs . 2010;29(7):1400–1406
  24. Naylor M , Kurtzman E . The role of nurse practitioners in reinventing primary care . Health Affairs . 2010;29(5):893–898
  25. Van Nes M , Sawatzky J . Improving cardiovascular health with motivational interviewing: A nurse practitioner perspective . J Am Acad Nurs Pract . 2010;22(12):654–660
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PII: S1555-4155(11)00362-X

doi:10.1016/j.nurpra.2011.07.026

The Journal for Nurse Practitioners
Volume 8, Issue 1 , Pages 51-55, January 2012

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