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ACOEM Practice Guidelines Perspectives on their use in guiding clinical care and utilization management

John P. Holland, MD, MPHPast-President, ACOEM

Chair, Guidelines Steering Committee

California Division of Workers’ Compensation

12th Annual Educational Conference

February 23 - 24, 2005 – Los AngelesFebruary 28 – March 1, 2005 – Oakland

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

Presentation Overview

Overview and Current Issues1. ACOEM perspective and

why EBM matters

2. Use of evidence in developing APGs

New Initiatives

1. APG Insights – newsletter

2. Utilization Management Tool (UMT)

3. Plans for the next generation of clinical practice guidelines

3

The ACOEM Perspective -

and why evidence-based medicine is important

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

The ACOEM Perspective

Our core mission - Promote the health and productivity of

workers, workplaces and the environment

Our core values - Use science to guide practice, programs

and policy Promote fairness for individuals, employers

and society Use processes that are inclusive, transparent

and rationally consistent

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

What is evidence-based medicine (EBM)?

“Evidence-based medicine is the conscientious,

explicit, and judicious use of current best

evidence in making decisions about the care

of individual patients.”

- David Sackett

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

Evidence-based medicine

Evidence-based Medicine

Gathering medical information

Evaluating quality of medical information

Making medical decisions using best evidence

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

Elements of EBM - identify relevant best evidence Define clinical question to be answered

(for a specific clinical situation)

Find best scientific evidence relevant to the specific clinical question (using systematic methods)

Rely on best evidence to guide clinical decision-making

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

Elements of EBM - identify relevant best evidence

Original evidence clinical epidemiology (e.g. clinical) trials descriptive epidemiology outcomes research / economic studies

Literature synthesis / analysis systematic literature reviews / meta-analyses clinical practice guidelines cost-effectiveness studies

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

Elements of EBM - focus on clinical outcomes

Clinical outcomes (things that matter to patients and families)

survival impairment / disability / disfigurement symptom severity quality of life (QOL) cost / convenience

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

Elements of EBM - use standard measures of effect

Evaluate therapies using standard measures:How does it affect rate, degree or timing of:– Physical impairment, disfigurement or death – Return to normal functioning– Symptom resolution– Potential harms (from therapy)– Total costs (for patient, employer and society)

Allows comparisons of benefits and harms of different clinical methods

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

Elements of EBM - assess likely benefits / harms

Evaluate clinical methods on benefits / harms– Beneficial – Likely to be beneficial– Trade off between benefits and harms– Unknown effectiveness– Unlikely to be beneficial– Likely to be ineffective or harmful

Promotes informed decision-making by clinicians and patients

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

Elements of EBM - base decisions on best evidence Find best scientific evidence that is

applicable to the specific clinical situation – individual patient’s clinical situation– program or policy decision

Use evidence to guide decision-making– does the likelihood of benefit outweigh likelihood

of harm enough to justify the cost?– same question applies to individual and society

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

EBM is important because - provides a science-based method for

Improving physician practice– increase effectiveness / decrease harms

(better clinical outcomes / cost-effectiveness) Increasing consumer knowledge

– understand potential benefits / harms

Building quality into healthcare systems– using practice guidelines, quality indicators

Guiding government / employer policies– guide programs / policies on healthcare

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

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Use of Evidence in Developing

the ACOEM Clinical Practice Guidelines (APGs)

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

What are clinical practice guidelines?

Clinical practice guidelines are

recommendations for clinicians and

consumers about optimal and appropriate

care for specific clinical situations

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

Formal or informal guidelines are the basis for all clinical practice

Basis for most clinical decisions

Foundation of clinical teaching

Mental short-cuts and memory aids for common or complex problems

Primary method to evaluate care patterns and monitor standards of care

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

Types of guidelines - major focus

clinical assessment / treatment – management of cardiac arrest (ACLS)

risk assessment / prevention – drugs to use in pregnancy (ACOG)

administrative – insurance pre-approval for surgery

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

When are guidelines needed ?

Institute of Medicine (IOM) criteria – clinical practice guidelines are useful when:

– the problem is common or expensive

– there is great variation in practice patterns

– there is enough scientific evidence to determine appropriate and optimal care

(IOM , 1992)

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

Types of guideline development approaches Single author - expert opinion

Single author - systematic literature review

Consensus panel using expert opinion only

Consensus panel using evidenced-based approach (AHCPR methodology)

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

Steps in developing guideline recommendations define clinical questions of interest develop summary of evidence on:

– clinical efficacy (potential benefits)– potential harms / projected costs

weigh likelihood of benefit versus likelihood of harms, and consider costs

develop finding / recommendation statements document all aspects of the process

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

Evidence-based guidelines - need to explicitly document

methodology and assumptions evidence reviewed summary of findings decision-making rules for recommendations rationale for each conclusion and

recommendation statement

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

Types of guideline statements

Based on AHCPR guidelines, the types of guideline statements are:

Recommendation for use

Option for use

Recommendation against use

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

Strength of evidence ratings for guideline recommendations

A = Strong research based evidence– multiple relevant, high quality studies

B = Moderate research based evidence– one relevant, high quality study

C = Limited research based evidence– one adequate study, somewhat relevant

D = Panel opinion – based on information not meeting criteria for A-C

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

Criteria for determining is a study contains “High quality” evidence Clinical epidemiology is the study of the

effectiveness of clinical assessment and treatment methods

There is general consensus among experts on what constitutes a high quality study – but specific criteria vary on subtle details

APGs relied on criteria for determining high quality studies used by the AHCPR low back guideline and Cochrane Reviews

ACOEM Practice Guidelines, 2nd Ed., page 501)

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ACOEM New Directions -

APG Insights

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

APG Insights - newsletter

Newsletter devoted to discussing issues relevant to use of the ACOEM Practice Guidelines (APGs)

Separate editorial board Anticipate about 6 issues per year First issue was in fall of 2004,

next issue in March 2005 For information go to acoem.org

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

APG Insights - purpose

APG Insights will Provide suggestions and examples on how APGs can

be used in clinical care / utilization management Provide summaries of scientific evidence (systematic

reviews) on clinical topics relevant to the APGs

APG Insights will not Explain or justify how APG were developed (APGs

must speak for themselves) Be a revision or update of the guideline

(no presumption of correctness in California)

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

APG Insights – Fall 2004- APG guidance on chronic conditions States “Unequivocally” that APGs do apply to

conditions after 90 days (chronic conditions)

APGs - “Mostly focus on the first 90 days following workplace injury because approximately 90% of injuries are resolved during this time period.”

Chapters 1-7 of APGs give general approach for assessment and treatment of injured workers - “These basic components remain constant

throughout the life of the claim”

Chapter 6 deals extensively with chronic pain (generally defined as pain lasting over 3-6 months)

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ACOEM New Directions -

Utilization Management Tool (UMT)

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

Utilization Management Tool

Purpose of UMT is to provide Accurate interpretation of APG recommendations

claims staff can rely upon in making decisions

Consistent interpretations to reconcile perceived inconsistencies within APG

Easy to use tool to foster efficient and consistent utilization management based on APG

Create written summary of relevant APG guidance relied upon in making claim decision (based on UMT)

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ACOEM New Directions -

Next Generation of Clinical Practice Guidelines

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

Next Generation of Clinical Practice Guidelines ACOEM is committed to moving to the “next level” in

working to develop a new generation of clinical practice guidelines

We continue to learn about how guidelines are best used in WC settings

We are committed to increasing scientific rigor, documentation and usefulness in future guideline development efforts

In our work on developing a new generation of practice guidelines – we are committed to following our core mission and core values in these efforts

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

The ACOEM Perspective

Our core mission - Promote the health and productivity of

workers, workplaces and the environment

Our core values - Use science to guide practice, programs

and policy Promote fairness for individuals, employers

and society Use processes that are inclusive, transparent

and rationally consistent

34

References Evidence-based medicine and practice guidelines

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

References – Evidence-based medicine and practice guidelinesBook chapters and journal articles

1. American College of Occupational and Environmental Medicine (2004). ACOEM Clinical Practice Guidelines, 2nd Edition. Glass L (Ed.). (Beverly Farms, MA; OEM Press).

2. Bigos SJ, et. al. (1994) U.S. Agency for Health Care Policy and Research (AHCPR) Clinical Practice Guideline #14: Acute low back problems in adults. Pub. 95-0642 (U.S. Department of Health and Human Services, Public Health Service, Rockville, MD).

3. Holland JP. (1995) Developing evidence-based clinical practice guidelines. Current Opinion in Orthopedics. 6: 63-69.

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

References – Evidence-based medicine and practice guidelinesBook chapters and journal articles (continued)

4. Holland JP, Holland CL, Webster JS, Bigos SJ. (2003) How to critically evaluate the literature on low back problems: The foundation for an evidence-based approach to care. Seminars in Spine Surgery. 15: 54-67.

5. Institute of Medicine, Committee on Clinical Practice Guidelines. (1992) Guidelines for Clinical Practice: From Development to Use. Field M, Lohr K (Eds). (Washington, DC; National Academy Press).

6. Sackett D, Haynes R, Guyatt G, et al. (1991). Clinical Epidemiology: A Basic Science for Clinical Medicine, 2nd Edition. (Boston, MA; Little, Brown).

John P. Holland, MD, MPHJohn P. Holland, MD, MPH

References – Evidence-based medicine and practice guidelinesBook chapters and journal articles (continued)

7. Sackett D, Straus S, Richardson W, et al. (2000). Evidence-based Medicine: How to Practice and Teach EBM. (New York, NY; Churchill Livingstone).

Websites

8. www.acoem.org - ACOEM’s website. For information on APG Insights, a newsletter on issues relevant to the ACOEM Clinical Practice Guidelines.

9. www.cochrane.org - The Cochrane Collaboration website; a source for systematic reviews on medical intervention