AAOS Bulletin - June, 2006

Why aren’t you doing evidence-based practice?

Don’t let common misconceptions prevent you from practicing evidence-based medicine

By Charles Turkelson, PhD, and Jill Elaine Hughes, MA

The terms evidence-based practice and evidence-based medicine are everywhere these days, but understanding what these terms mean and how to apply them to the daily practice of orthopaedics is elusive. Because the evidence base for both new and established orthopaedic surgical procedures is often scant, finding justification for basing all your medical decisions on scientific evidence can be challenging.

In addition, orthopaedics has a strong tradition of relying solely on expert opinion. But in a payment environment that is trending toward performance-based compensation (pay-for-performance), evidence-based practice will soon be essential for every physician’s economic and professional survival.

The 2001 Institute of Medicine (IOM) report, Crossing the Quality Chasm, reported that on average, it takes at least 17 years for new, effective medical research findings to become standard medical practice. This and other IOM reports also found that the lack of national evidence-based practice standards contributes to a highly fragmented health care system in which care for the same condition varies greatly from clinician to clinician and from region to region.

Heavier reliance on evidence-based practice tools such as rigorously developed practice guidelines and performance measures, as well as improvements in information technology such as standardized electronic health records, can help close this quality chasm and improve patient care.1

Sounds like a win-win situation, right? Then why are so many physicians slow to adopt evidence-based practice? There are several reasons, both personal (attitudes and habits) and business (economics). But in most cases, these reasons are actually misconceptions.

Some physicians regard evidence-based practice as just another passing fancy of the insurance industry. Others are comfortable with the methods they learned in medical school 30 years ago (“I’ve always done it this way, so I know it works!”).

Still others are reluctant to adhere to elements of evidence-based practice such as outcomes data collection, which can be prohibitively expensive, especially for small private practices. Some physicians fear increased medical liability risk for following a practice paradigm that may be supported by scientific evidence, but still falls outside the legal definition of “standard of care” (a medical practice routinely employed by 51 percent or more of physicians in a given specialty and geographic region).

To determine how real these concerns are, let’s examine each.

“A passing fancy”?

Misconception No. 1: Evidence-based practice and pay-for-performance are just passing fancies of the insurance industry.

Nothing could be further from the truth. The need for improving health care quality via evidence-based medicine was first publicly emphasized by the Institute of Medicine in its special Congressional reports To Err Is Human (1999) and Crossing the Quality Chasm—both of which have received widespread accolades and validation from organized medicine.

In addition, according to a recent RAND study on American health care quality, Americans receive optimal care only 54.9 percent of the time. (For optimal care of common orthopaedic conditions such as hip fracture, this number drops to 22.8 percent.)2 Research therefore shows substantial room for quality improvement in American medicine, and increased adherence to evidence-based practice can help bring about this improvement.

“It works for me”

Misconception No. 2: Who needs evidence? I’ve always done it this way, and I know it works!

The difficulty with this argument is simple: “it” doesn’t always work. Numerous orthopaedic/surgical procedures once thought to be beyond reproach were shown to provide no real benefit (or were even harmful) when they were studied more closely.

The “one-knife technique,” for example, has been shown to be as safe and effective at infection prevention as the formerly universal standard of using separate skin and inside knives in surgery.3 Antibiotic prophylaxis more than 24 hours postsurgery—once thought to prevent infection—has been shown time and again to be ineffective.4,5 Although six weeks’ prescribed bed rest for low back pain was the accepted standard of care for 30 years, it is now universally known to be ineffective and perhaps even detrimental.6,7

Furthermore, without systematic long-term outcomes tracking, it is difficult to assert with any real certainly whether a given intervention provides a measurable benefit to patients over the long haul.

“Who can afford it?”

Misconception No. 3: Evidence-based practice is just too expensive.

While the short-term cost of adapting one’s practice to an evidence-based model is indeed quite high (especially if your practice has little-to-no existing information technology infrastructure for data collection and reporting), the longer-term cost—losing reimbursements for failing to meet quality benchmarks—is significantly higher. Furthermore, quality care—which is designed to be safe, to prevent unnecessary complications and overuse of services as well as underuse of established cost-saving prophylaxis methods—generally is cheaper than poor quality care, which can result in costly complications, unnecessary treatments and liability-inducing medical errors.

“It’s too risky”

Misconception No. 4: Evidence-based practice is great in theory, but I’m afraid if I follow evidence-based guidelines, I’ll get sued.

This concern arose among physicians in recent years, especially following a high-profile anecdotal report published in the Journal of the American Medical Association (JAMA) in 2004. This anecdotal report relayed how an on-call emergency room resident (Daniel Merenstein, MD) and his residency program were successfully sued for malpractice—solely on the basis of their strict adherence to the latest evidence-based clinical practice guidelines (CPGs).8

Many physicians read Dr. Merenstein’s account in JAMA and became alarmed about the liability “risks” of adhering to the latest advances in evidence-based practice, especially in regions where doing so was still outside the parameters of antiquated, ineffective “standards of care.” This physician alarm quickly grew and spread for several reasons, in part because little data existed in either current medical or legal literature that disputed Dr. Merenstein’s assertion.

Dr. Merenstein’s bad experience, however, shouldn’t scare orthopaedists away from evidence-based practice. His medical liability lawsuit loss, which received a great deal of attention in the medical press, is the exception rather than the norm. Recent medical literature on this issue indicates that adherence to evidence-based practice, CPGs and shared decision making most often prevents malpractice cases from even being filed in the first place.9,10

In cases that are filed, physician adherence to evidence-based CPGs more often provides the necessary exculpatory evidence to settle the case in the physician’s favor.11 Provided you adhere to evidence-based practice guidelines and performance measures that were developed according to rigorous, universally accepted scientific methods, your actions should be highly defensible in court.

Basing decisions on the evidence

Based on the current evidence, a definite shift to evidence-based practice should be expected. Future issues of the AAOS Bulletin will devote considerable attention to this hot topic, so stay tuned for more information to help make your orthopaedic practice more evidence-based.

Charles Turkelson, PhD, is director of the AAOS department of research and scientific affairs. Jill Elaine Hughes, MA, is AAOS clinical quality improvement coordinator and staff liaison to the AAOS Evidence-Based Practice Committee.

References:

1. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. National Academies Press, 2001, pp 8-25.

2. McGlynn EA, Asch SM, Adams J, et al. The Quality of Health Care Delivered to Adults in the United States. N Engl J Med 2003;348:2635-45.

3. Schindler OS, Spencer RF, Smith MD. Should we use a separate knife for the skin? J Bone Joint Surg (Br) 2006;99-B:382-5.

4. Bratzler DW, Houck PM, Richards C, et al. Use of antimicrobial prophylaxis for major surgery: baseline results from the National Surgical Infection Prevention Project. Arch Surg 2005 Nov;140(11):1066-7.

5. Malik MH, Chougle A, Pradhan N, Gambhir AK, Porter ML. Primary total hip replacement: a comparison of a nationally agreed guide to best practice and current surgical technique as determined by the North West Regional Arthroplasty Register. Ann R Coll Surg Engl 2005 Mar;87(2):117-22.

6. Arnau JM, Pellise F, Vallano A, Prat N. A critical review of guidelines for low back treatment. Eur Spinr J 2005 Oct 11; [Epub ahead of print].

7. Hagen KB, Jamtvedt G, Hilde G, Winnem MF. The updated Cochrane review of bed rest for low back pain and sciatica. Spine 2005 Mar 1;30(5):542-6.

8. Merenstein D. Winners and losers. JAMA 2004;291:15-16.

9. Hyams AL, Brandenburg JA, Lipsitz SR, Shapiro DW, Brennan TA. Practice Guidelines and Malpractice Litigation: A Two-Way Street. Ann Intern Med 1995;122:6:450-55.

10. Pelly J, Newby L, Tito F, Redman S, Adrian AM. Clinical practice guidelines before the law: sword or shield? Med J Aust 1998;169:330-333.

11. Hurwitz B. How does evidence-based guidance influence determinations of medical negligence? BMJ 2004 Oct 30;329(7473):1024-8.


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