Clinical Guidelines: Building Blocks Clinical Guidelines: Building Blocks for Effective Chronic Illness Carefor Effective Chronic Illness Care

Jean Slutsky, P.A., M.S.P.H.Jean Slutsky, P.A., M.S.P.H.Director, National Guideline ClearinghouseDirector, National Guideline Clearinghouse

Project Director, US Preventive Services Task ForceProject Director, US Preventive Services Task ForceU.S. Agency for Healthcare Research and QualityU.S. Agency for Healthcare Research and Quality

Finding the EvidenceFinding the Evidence

Approximately 8,000 completed Approximately 8,000 completed references are added to MEDLINE each references are added to MEDLINE each week (over 400,000 added per year)week (over 400,000 added per year)

Too much for any one person to evaluateToo much for any one person to evaluate

Uncertainty results in:Uncertainty results in:– variations in carevariations in care– under and over utilization of servicesunder and over utilization of services

Putting Evidence into PracticePutting Evidence into Practice

It may take as long as 17 years for original It may take as long as 17 years for original research to be put into routine clinical practiceresearch to be put into routine clinical practice

Source: Balas EA, Boren SA. Managing Clinical Knowledge for Health Source: Balas EA, Boren SA. Managing Clinical Knowledge for Health Care Improvement. Yearbook of Medical Informatics. Schattauer, 2000: Care Improvement. Yearbook of Medical Informatics. Schattauer, 2000: 65-70.65-70.

Documented Variation in Treatment Documented Variation in Treatment of Congestive Heart Failureof Congestive Heart Failure

79%

23%

64%

8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

PrescribedACE

Counseledon Salt

Source: Effective Clinical Practice, March/April 2000

69 hospitals in 5 states;2077 patients with CHF

Under-use of Beta-blockersUnder-use of Beta-blockers Despite strong evidence that use of beta-blockers

following acute myocardial infarction (AMI) decreases morbidity and mortality, they are substantially under used in the elderly.

Beta-blocker prophylaxis after AMI is one of the most scientifically substantiated, cost-effective medical services. Their use decreases cardio-vascular mortality and reinfarctions, and increases survival by 20% to 40%.

Under use leads to excess 2-year mortality and re-hospitalization for cardiovascular disease.

Source: JAMA January 8, 1997; 277: 115-121Source: JAMA January 8, 1997; 277: 115-121

Under-use of Beta-blockers (cont’d)Under-use of Beta-blockers (cont’d) Only 21% of eligible New Jersey Medicare Only 21% of eligible New Jersey Medicare

beneficiaries received beta-blocker therapy beneficiaries received beta-blocker therapy following their heart attack. following their heart attack.

Calcium channel blockers were used almost 3 Calcium channel blockers were used almost 3 times as often despite a lack of evidence that they times as often despite a lack of evidence that they decreased mortality. decreased mortality.

Patients on beta-blockers were re-hospitalized Patients on beta-blockers were re-hospitalized 22% less often and their mortality rate was 43% 22% less often and their mortality rate was 43% lower than non-recipientslower than non-recipients. .

Patients receiving calcium channel blockers Patients receiving calcium channel blockers instead of beta-blockers instead of beta-blockers doubled their risk of deathdoubled their risk of death

Source: Source: JAMA January 8, 1997; 277: 115-121 JAMA January 8, 1997; 277: 115-121

Examples of Quality of Examples of Quality of Chronic Health CareChronic Health Care

52% of elderly adults received a flu shot in 52% of elderly adults received a flu shot in 19931993

33% of hospitalized elderly discharged on an 33% of hospitalized elderly discharged on an anti-depressant were on a dose below anti-depressant were on a dose below recommended levelrecommended level

49% of diabetic adults had dilated eye exam 49% of diabetic adults had dilated eye exam in past year in past year

43% of patients who should have received 43% of patients who should have received coronary angiography received it within 3 coronary angiography received it within 3 monthsmonths

Source: M.A. Schuster et al., Source: M.A. Schuster et al., Milbank Q,Milbank Q, 1998; 76:517-563 1998; 76:517-563

Chronic Care ManagementChronic Care Management

Do the Do the RIGHTRIGHT thing to the thing to the RIGHTRIGHT patient at patient at the the RIGHTRIGHT time. time.

Guidelines Can Improve Guidelines Can Improve Clinical DecisionsClinical Decisions

Clinical guidelines based on critical appraisal ofClinical guidelines based on critical appraisal of scientific scientific evidence (evidence-based guidelines) clarify whichevidence (evidence-based guidelines) clarify which

interventions are of proven benefit and document quality interventions are of proven benefit and document quality ofof supporting data. supporting data. – Alert clinicians to interventions unsupportedAlert clinicians to interventions unsupported by good scienceby good science

– Reinforce the importance and methods of criticalReinforce the importance and methods of critical appraisalappraisal

– Call attention to ineffective, dangerous, and wastefulCall attention to ineffective, dangerous, and wasteful practices practices

Source: Source: BMJBMJ 1999;318:527-530 ( 20 February ) 1999;318:527-530 ( 20 February )

In SummaryIn Summary Chronic illness care should Chronic illness care should

be based on the best be based on the best available evidenceavailable evidence

““Stop, look, and listen” and Stop, look, and listen” and make sure that you know make sure that you know what you are using: who what you are using: who developed it, how good is the developed it, how good is the information, and is it currentinformation, and is it current

www.guideline.govwww.guideline.gov provides provides access to evidence-based access to evidence-based guidelinesguidelines