Alan M. Muney, MD, MHA

This means using a carrot-and-stick approach with physicians. Those who respect the evidence should be rewarded; others should face penalties.

Alan M. Muney, MD, MHA

Measuring physician practices and resulting outcomes is not easy. There is variability in the complexity of patients, from their biological response to treatments to their attitudes toward treatment. However, statistical measurements of adherence to clinical practice guidelines can be done well and can correct for variations in patient complexity.

The truth is that evidence-based medicine will help doctors give more rational care — and will result in better outcomes for patients. Guidelines are not meant to be inflexible; they are simply the best first step. In certain cases, patients may be sicker or may have specific issues that require treatment outside of the guidelines. That is when judgment and years of medical training come into play.

The need to push toward evidence-based medicine nationwide is obvious amid reports of gross outcome inequities in different geographic regions. If all American doctors practiced evidence-based medicine, we would no longer find six times as many angioplasties per 1,000 Medicare beneficiaries performed in Elyria, Ohio, as are done in York, Pa.

It would mean all U.S. heart attack sufferers received guideline-recommended ACE inhibitors, rather than the 31 percent that the American Heart Association reports are currently receiving the proven treatment.

It would turn around the fact that two thirds of the nation's trauma hospitals don't follow the guidelines for treating head injury (the leading cause of death for people age 1 to 45). The Brain Trauma Foundation says 10,000 of the 52,000 brain trauma deaths each year are due to failure to follow guidelines.

Two dramatic steps

The outcomes have been proven across disease categories and across geographic lines. After adopting the guidelines for treating head injury, Inova Fairfax Hospital in Falls Church, Va., saw a 33-percent decrease in deaths due to severe head trauma. Hospital charges for care dropped 25 percent once the guidelines were put into action.

Similarly, Valley View Hospital in Glenwood Springs, Col., adopted guidelines for treatment of one of its top volume conditions: community-acquired pneumonia. After guidelines were adopted, unplanned readmissions within 30 days decreased by 36 percent.

Though there are signs that a movement toward evidence-based medicine is afoot in the United States, it seems destined to plod along, at the risk and expense of patients who don't have valuable time and money to waste on treatments that don't work. Accelerating adherence among doctors will require two dramatic steps.

  1. All medical schools must focus on teaching evidence-based medicine to their physicians in training. Currently, just 11 of the 125 medical schools in the United States teach a separate, required course on evidence-based medicine. After medical students graduate and go into practice, this training should be reinforced by continuing medical education throughout their careers. Studies should track these medical school graduates to determine whether they practice what has been preached to them.
  2. Enforcement is essential. To ensure that physicians don't arbitrarily ignore guidelines, state health departments should measure doctors' adherence to guidelines for such basic illnesses as diabetes, heart disease, hypertension, asthma, and chronic pulmonary disease. HMOs can do their part by monitoring doctors in their network. The linchpin of enforcement, however, involves state licensing agencies, which need to establish a suspension system for recalcitrant doctors.

Brandish the stick

Physicians who repeatedly refuse to correct their treatment methods, even after independent expert review substantiates the failures, should face license suspension.

Much of the angst between patients and health plans that we hear about on the evening news occurs when health plans determine that requested procedures lack appropriateness according to guidelines, even when individualized patient care issues (the "art of medicine") are discussed by treating physicians and health plan medical directors.

In the agonizingly slow crawl toward evidence-based medicine, the evidence shows that it is not just the proven outcomes that will influence physician behavior. The only way to dramatically change the way U.S. physicians practice medicine is to take this dramatic two-pronged approach. First, teach evidence-based medicine to all doctors in training, who will then become life-long students of the available medical evidence for treatment of their patients' conditions.

Then, give teeth to the argument that guidelines should be the first step for any physician treating any condition by getting state health departments, health plans, and state licensing boards to measure practice patterns against accepted guidelines and putting those physicians who aren't performing adequately on a quality-improvement program.

Those who fail to correct problems after remedial education efforts should be put out of business. Only then can patients be assured that the medical care they are receiving is what they need — no more and no less.

Offer the carrot

Conversely, those physicians who consistently demonstrate excellence in practice should be rewarded for their efforts. This approach will, no doubt, be fought by medical societies as they strive to protect the compensation of even the lowest-common-denominator physicians.

Until organized American medicine embraces accountability through licensing actions and rewards incentives, the reduction of clinical practice variation will not occur and America will continue to fall short of its realistic goal: providing the "best doctors" and the "best medicine" at lower costs.

Alan M. Muney, MD, MHA, is the chief medical officer and an executive vice president of Oxford Health Plans.

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