Evidenced-Based

Medicine
MHM 07 - OPERATIONS MANAGEMENT IN HEALTHCARE
EMILIO AGUINALDO COLLEGE
Coverage
Evidenced-Based Medicine
Background
Standard & Customized
Patient Care
Chronic Disease Management
Home Healthcare
Tools to Expand EBM
Issues in P4P
Future of EBM
Evidenced-Based Medicine
➢ Conscientious & judicial use of the best current evidence in making
decisions about the care of individual patients – can result in better
clinical outcomes, reduce costs
➢ 3 major phases for expansion of clinical knowledge:
1. Basic research done in lab & w/ animal models
2. Carefully controlled clinical trials to demonstrate efficacy of
diagnostic/treatment
3. Clinical trial results are translated to clinical practice
Evidenced-Based Medicine
➢ Need to consistently apply EBM
➢ Major tool is clinical practice guideline, w/c is a systematically
developed statements to assist practitioner & patient decisions about
appropriate healthcare for specific clinical circumstances
Evidenced-Based Medicine
Barriers to application of EBM: doctor
1. Lack of knowledge that guidelines exist for a specific condition
2. Lack of familiarity w/ details of guidelines
3. Disagreement w/ guideline recommendation
4. Inability to effectively apply the guideline’s recommendation
5. Lack of trust in effectiveness of guideline
6. Resistance to change & reliance on habits
7. External factors – financial, organizational factors
 Evidenced-Based Medicine
Barriers to application of EBM: patient
1. Patient characteristics – lack of social support or
psychiatric/psychological co-morbidity
2. Patient difficulty in recognizing symptoms & adhering to therapies for
the symptoms
3. Complex therapeutic regimen
4. Relationship & personal interaction between patient & physician

How can health care managers address

these barriers – for patients and
doctors?
Standard & Custom Patient
Care
➢ Criticism of EBM is that all patients are unique
➢ All healthcare is a blend of custom & standard care (Bohmer, 2005)
➢ There are 4 models stated
Standard & Custom Patient
Care
Model A (seperate & select)
Initial sorting of patients
themselves
Standard problems are tx w/
standard care using EBM
guidelines
Patients who do not fit
homogenous clinical condition are
referred out
Laser eye surgery
Standard & Custom Patient
Care
Model B (seperate & accomodate)
Combines 2 methods in 1 provider;
accommodates both
1 unit for standard care; 1 unit for
custom care
Units review patient’s case
regularly
Standard & Custom Patient
Care
Model C (modularized)
Clinician is architect of care design
for patient
A number of standard processes
are assembled to treat patient
After initial evaluation, treatment
of different types; different
professionals
Standard & Custom Patient
Care
Model D (integrated)
Combines standard care & custom
care in 1 org
@ patient receives mix of custom
& standard care
Clinicians encouraged to override
elements in protocols when in best
interest of patients

Can you give examples for each model?

Financial Gains from EBM
➢ Can decrease total cost in the system
◦ Preventive Quality Indicator (PQI) – set of measures that can be used
w/ hospital discharge data to identify patients who may have
hospitalizations, complications that could have been avoided w/ use
of evidence-based ambulatory care.
◦ Preventable hospitalizations avoided by high-quality outpatient
treatment & disease management
Chronic Disease Management
➢ One of the most expensive care is chronic disease management (e.g.
Diabetes, COPD, congestive heart failure)

➢ Variation in outcomes due to providers’ & patients’ lack of adherence

to EBM

➢ Study: patients enrolled in chronic care mgt. programs had fewer

readmissions & readmission days
Chronic Disease Management
Chronic Care Model (Wagner, 2001)- widely accepted model for chronic
disease mgt.
➢ Population-based outreach – all patients in need, receive it
➢ Treatment plan created are sensitive to patient preferences – EBM,
clinical info systems, built-in decision support
➢ Patient encouraged to change risky behaviors, manage self better
➢ More time for interaction between MD & ptt w/ complicated issues
➢ Routine or specialized matters handled by various professionals.
Home Healthcare
3 components for success: (Milstein & Gilbertson, 2009)
1. Individualized & intense caring for patients w/ chronic illness
2. Efficient service provision
3. Careful selection of specialists (considering quality & cost)

What do you think is the future

of Home Healthcare in the
Philippines given the present
situation?
Tools to Expand Use of EBM
➢ Value purchasing – new programs focused on encouraging increased
implementation of EBM; include public reporting of clinical results &
pay-for-performance

Public Reporting
➢ Strongly resisted by clinicians
➢ Reports performance of hospitals, long-term care facilities, medical
groups, performance & prices of providers
Tools to Expand Use of EBM
Issues on Public Reporting:
1. Risk adjustment – clinicians feel their patients are “sicker” than
average & contemporary risk adjustment systems do not adequately
account for this
2. Patient compliance – should MD be faulted for patient’s non-
compliance?

Public reporting system appears to be

affecting quality of care
 Tools to Expand Use of EBM
Pay for Performance (P4P) & Payment Reform
➢ Add payments to the amount that would otherwise be paid to a
provider; provider must demonstrate that he is delivering care that
meets clinical EBM goals to obtain the additional payments
➢ Clinical measures can be process or outcome measures
➢ Outcome measures difficult to use: some outcomes need to be
measured over many years, some providers have small no. of patients
so outcomes vary dramatically
➢ Process measures are used for many conditions, backed by extensive
EBM literature. e.g. Blood pressure control & diabetes

Can you provide examples where P4P would be useful?

 Tools to Expand Use of EBM
General Payment Reform Model
Cost containment goals
• Reverse the fee-for-service
incentive to provide more
services
• Provide incentives for
efficiency
• Manage financial risk
• Align payment incentives to
support quality goals
Quality goals
• Increase or maintain
appropriate & necessary
care
• Decrease inappropriate care
• Make care more responsive to
patients
• Promote safer care
Future of EBM
One of the challenges of widespread use of EBM is since it is based on
clinical studies of many patients, w/c result in averaged results; but no
patient is completely average – clinicians frequently vary from guidelines
to compensate
Archimedes Model – full-scale simulation model of human physiology,
diseases, behaviors, interventions, healthcare systems. Integrated into a
large-scale simulation model representing what happens to real people in
real healthcare systems
Big Data being used to handle large volumes of information, processing
very quickly