A rapidly growing movement is using evidence-based medicine to enhance safety, improve quality, and lower costs in healthcare delivery.

In American hospitals, central line infections cause as many as 28,000 deaths per year—the entire population of the city of Newburgh, NY. What makes that number truly terrifying is that catheter-related bloodstream infections are completely preventable when the right evidence-based procedures are followed.

It’s statistics like this that led the Institute of Medicine to declare in 2001, “Between the healthcare we have and the care we could have lies not just a gap, but a chasm.”

But now, more than ever, organizations are coming together to fill that chasm by putting a new spin on an old idea: evidence-based medicine (EBM). Until recently, EBM was all about drug A being better than drug B. Now, a rapidly growing movement is making EBM about the processes and best practices proven to enhance safety, improve quality, and lower costs in healthcare delivery.

“That’s where the cutting edge of EBM is now,” said Dr. Brian Haynes, professor and chair at the McMaster University department of clinical epidemiology and biostatistics. Haynes was among the handful of Canadian doctors that developed the concept of EBM in the early 1990s. He’s seen evidence-based medicine evolve from a philosophy into a movement, and he’s never been more excited about its potential.

“It’s in its adolescence right now, and I think we’re just seeing the beginning of its impact. The things that are happening to integrate evidence into the delivery of health services will have a huge payoff in the future. And that future is closer than you think.”

From Canada to the world
Dr. David Sackett, the so-called father of evidence-based medicine, described it as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”

The philosophy is simple, and considered “old hat” by some, but putting it into practice isn’t nearly as easy. The main problem numerous early embracers of EBM ran into had to do with the wealth of research regularly published in more than 120 medical journals. There are so many studies in so many publications, it’s difficult to keep up with them all. And the majority of information published is communication between scientists that’s not ready for clinical consumption.

To help, Sackett published a book, Evidence-Based Medicine (Churchill Livingstone, 1996), detailing a critical appraisal process for identifying the very small subset of proven clinical information in the abundance of published articles. By that time, Haynes and the group at McMaster University were also publishing EBM journals for the American College of Physicians and British Medical Association.

“These publications were part of our effort to make it easier for practitioners to find studies worth paying attention to,” Haynes said. “Now doctors could concentrate on a subset of articles that had already been appraised for quality.”

Today, EBM has entered the electronic age. At McMaster University, a crack research team scours medical journals as they’re published, applying Dr. Sackett’s critical appraisal process to find the roughly 2% of studies ready for clinical practice. The qualified articles are then sent to a panel of 4,000 physicians worldwide, rated, separated by discipline, and entered into a database. Clinicians can access the database for free and tailor it to provide them with updates specific to their practice.

At the practice level, EBM may have reached its peak. But long before it did, Haynes and his team were asking how EBM could continue to evolve into the next frontier—the delivery of health services at the hospital level. It was a question being asked by numerous other organizations as well, most notably in Cambridge, Mass. at the Institute for Healthcare Improvement.

Infrastructure for change
IHI, a not-for-profit founded in 1991, recognized the chasm between the evidence-based best practices for care and their implementation—a chasm that created an estimated 15 million unnecessary incidents of patient harm in US hospitals each year.

In 2004, the institute brought together more than 200 organizations—hospitals, quality improvement organizations, and other healthcare entities—to create a national infrastructure for change. The result was the 100,000 Lives Campaign, an ambitious program designed to reduce harm and save lives in hospitals by implementing six key, evidence-based interventions.

“As we select interventions for our campaigns, one of the key criteria for us is that there is a sound evidence base,” said IHI vice president Joseph McCannon. “Clinicians and the literature very strongly confirm the practices being discussed are very efficacious, and they make a meaningful difference in outcomes for patients.”

Starting in January 2005, IHI helped hospitals across the country deploy rapid response teams at the first sign of patient decline; deliver reliable, evidence-based care for acute myocardial infarction; prevent adverse drug events by implementing medication reconciliation; prevent central line infections by implementing the Central Line Bundle; prevent surgical site infections by reliably delivering the correct perioperative antibiotics at the proper time; and prevent ventilator-associated pneumonia by implementing a series of scientifically proven best practices.

By the time the organization hit its 18-month deadline, more than 3,100 hospitals were on board and an estimated 122,300 lives had been saved. For many in the industry, it was an eye-opening campaign that demonstrated just how powerful the implementation of evidence-based health services could be in improving healthcare in the US.

Dr. Donald Berwick, president and CEO of IHI, said at first he didn’t know if it was a challenge America’s hospitals would accept. “But the campaign exceeded our highest expectations. The participating hospitals have not only prevented an estimated 122,300 deaths, they’ve also proven that it’s possible for the healthcare community to come together voluntarily to rapidly make significant changes in patient care.”

Added McCannon, “This vibrant infrastructure is not going away—in fact, together we fully intend to build on it to completely transform the healthcare system.”

Why not everyone?
The 100,000 Lives Campaign answered many questions about evidence-based medicine, but it also raised an important question: Why weren’t more hospitals incorporating these proven, life-saving best practices?

According to McCannon, there are a handful of reasons: there is often debate as to when the evidence is robust enough for a practice to be considered worth implementing; organizations often don’t have the human or capital resources required for implementation; and because hospitals are complex, often chaotic places, it can be difficult to implement sustainable change.

“Evidence-based medicine is a two-part issue: nailing down the evidence base and then figuring out how we can make it happen reliably,” McCannon said. “As you get closer to it, you realize how challenging it is, but also how possible it is.”

A strong example of the dilemma is the EMC model for acute myocardial infarction (AMI). Because AMI care includes so many different providers, IHI senior fellow Dr. David Calkins said in a statement, following all seven of the best practice treatment guidelines in a timely manner can be difficult.

“The patient typically starts in the ED, where many of the early elements of AMI intervention need to happen,” he said. “Later on, others take over the responsibility for things such as ACE inhibitors, and smoking cessation counseling often happens at the end of the hospital stay. Getting all this right requires good communication among providers every step along the way.”

Recognizing the challenges its interventions posed, IHI went the extra mile to help hospitals through the change process. The organization created a list of mentor hospitals for each intervention; offered detailed guidelines, tools, and metrics for implementation; created robust learning communities; and offered the services of regional field offices in all 50 states. The approach was so effective that IHI far overshot its original goals and garnered the support to take its campaign to an entirely new level: The 5 Million Lives Campaign.

Launched in December, the campaign includes six new evidence-based interventions, and more than 3,500 hospitals are already participating. “For every one of these interventions, we’ve seen remarkable progress and change,” McCannon said. “Our hope is that, in as short a time interval as possible, we’ll see a significant transformation in America’s healthcare system.”

Evidence-based future
The signs that evidence-based medicine is making its way into health services are everywhere. Along with the thousands of hospitals taking part in The 5 Million Lives Campaign, the Joint Commission recently announced major changes in its National Patient Safety Goals.

Similar to IHI’s new evidence-based intervention designed to reduce harm from high-alert medications, the Joint Commission is requiring its 15,000 accredited health providers to reduce the risks of patient harm associated with the use of anticoagulant therapy by introducing evidence-based best practices.

CMS is partnering with states to share best practices and improve the quality of care administered to Medicare, Medicaid, and SCHIP patients. The organization recently announced its Medicaid/SCHIP Quality Strategy with evidence-based care listed as a top priority. At the Institute of Medicine, a roundtable on evidence-based medicine has been established, bringing together key stakeholders to develop ways that evidence can be better developed and applied.

And at McMaster University, Dr. Haynes and his team have partnered with McMaster Hospital to create a best practices research institute. The institute not only seeks to improve the quality of care, it’s working to improve the dissemination of validated new processes.

Health IT providers are also jumping on board. Companies like New York-based ActiveHealth Management are working to incorporate evidence-based medicine and electronic health records. ActiveHealth’s CareEngine applies a comprehensive set of updated, evidence-based clinical rules to aggregated patient data and alerts physicians to help prevent clinical complications and lower medical costs.

“There are a lot of entities that can pop up guidelines specific to the evidence-based treatment of problems such as heart failure,” said Dr. Lonny Reisman, CEO. “What’s distinguished us is our ability to not only pop up the guideline, but to relate the essence of those guidelines to the specific patient’s data. We can then highlight discrepancies between the evidence-based best practice and the care being provided.”

Reisman said it’s just a matter of time before ActiveHealth is able to integrate CareEngine with CPOE systems and full-fledged EMRs. As Dr. Haynes noted, “The things that are happening to integrate evidence into the delivery of health services will have a huge payoff in the future.