Evidence Based Medicine

More on Less

Steven Peskin MD

In April of last year, I wrote about the first release of recommendations from the American Board on Internal Medicine Foundation in conjunction with nine medical societies as part of a campaign: Choosing Wisely. The campaign aims to draw attention to and call into question commonly ordered tests like chest x-rays before surgery, frequently performed procedures like colonoscopies, and frequently prescribed treatments like antibiotics for upper respiratory infections. The campaign is directed to clinicians and patients with both audiences asked to consider the evidence for not doing select tests and procedures in specific circumstances where the evidence supports not doing the test or procedure or treatment. 

Fast forward 10 months. The ABIM Foundation has released 90 more recommendations in conjunction with medical specialty societies for physicians, other clinicians, and patients/consumers asking us to consider the evidence and to choose wisely. We should applaud the ABIM Foundation, the National Physician Alliance, Consumer Reports and the dozens of medical specialty societies that have assumed the mantle of leadership to bring this information to health care professionals and to consumers in clear, crisp, and concise statements. 

Steven R. Peskin, MD, MBA, FACP, is associate clinical professor of medicine at the University of Medicine and Dentistry of New Jersey — Robert Wood Johnson Medical School.

What Happened to EBM?

The drumbeat of EBM — Evidence Based Medicine — seems less vigorous in the wake of enthusiasm for new models of care — Medical Homes and Accountable Care Organizations — and reimbursement based on performance, outcomes, or episodes of care. A good definition of EBM from Sackett, et. al:

Evidence based medicine is 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 expertise with the best available external clinical evidence from systematic research. http://www.bmj.com/content/312/7023/71.full

In my view, evidence based medicine and evidence based practice will be central to the success of these delivery, risk sharing or risk shifting reimbursement models. A useful construct for implementation of EBM or EBP:

  1. Translation of uncertainty to an answerable question
  2. Systematic retrieval of best evidence available
  3. Critical appraisal of evidence for validity, clinical relevance, and applicability
  4. Application of evidence in practice; and
  5. Evaluation of performance

Managed Care Organizations can and should play a key role in numbers 1–3 and number 5 above. Payers and their provider networks will need to effect collaboration, share knowledge and learning, and orchestrate some degree of administrative and clinical data integration to put meaning into meaningful use and to achieve meaningful improvement in outcomes and affordability.

Steven R. Peskin, MD, MBA, FACP is executive vice president and chief medical officer of MediMedia USA, which publishes Managed Care. He is Associate Clinical Professor of Medicine at the University of Medicine and Dentistry of New Jersey–Robert Wood Johnson Medical School