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February 2016

Evidence-Based Practice Centers Offer Clues to Quality Care
By Amanda Griffith
For The Record
Vol. 28 No. 2 P. 6

Amid continued pressures to minimize errors and cut costs, health care organizations continue to scramble to find solutions that address these goals. For some hospitals, evidence-based practice centers (EPCs) may be the answer, according to a new University of Pennsylvania School of Medicine study published in the Journal of Hospital Medicine. In the report, researchers suggest hospital EPCs can effectively inform decision making and help develop solutions that influence national guidelines and coverage decisions.

In the first comprehensive assessment of the role of EPCs in decision making in a US hospital, the study's authors say the centers can help clinical and administrative leaders understand problems and evaluate possible solutions by reviewing the available scientific literature when national guidelines are unavailable, thus filling a critical knowledge gap. By moving the published evidence into practice, organizations can improve the quality, safety, and value of care and enhance the relationship between clinicians and administrators.

"At Penn, our hospital EPC's mandate is to integrate evidence into institutional practice, both inpatient and outpatient, to support the quality, safety, and value of care delivered across the board," says Craig A. Umscheid, MD, MSCE, the study's senior author and an assistant professor of medicine and director of Penn Medicine's Center for Evidence-Based Practice (CEP). "Equally important is implementing training in evidence-based quality improvement to help not only medical students but also faculty, clinical nurse specialists, and other clinical and administrative staff responsible for quality and safety."

The study found that nearly 250 reports were produced in the CEP's first eight years, with clinical departments, chief medical officers, and purchasing committees the most common requestors. While most of the reports reviewed drugs and devices, the range of topics spanned from care processes and organizational systems and policies to medical and surgical procedures. To underline the importance of the evidence reviews, 79% of requestors "agreed" or "strongly agreed" when asked whether the generated report informed their decision. Respondents also found the reports easy to request and to use, as well as timely and relevant, resulting in high requestor satisfaction.

A Growing Movement
Established in 2006, Penn Medicine's CEP is staffed by a hospitalist director, three research analysts, six physician and nurse liaisons, a health economist, a biostatistician, an administrator, and librarians. To accomplish its mission of strengthening care quality, safety, and value, the CEP performs rapid systematic reviews of published research, translates evidence into practice using computer-based interventions in EHRs, and educates trainees, staff, and faculty on evidence-based decision making.

Penn is not alone in its efforts—it's home to one of 13 EPCs supported by the Agency for Healthcare Research and Quality (AHRQ), which created the program in 1997 to conduct evidence reviews for the Effective Health Care initiative, which serves the needs of federal programs and medical societies, among others. In 2011, the Institute of Medicine, for its part, published two reports that outlined standards for developing rigorous and trustworthy systematic reviews and clinical practice guidelines.

Other EPCs include those overseen by Duke University, Brown University, Johns Hopkins University, and the Mayo Clinic. In addition, a multidisciplinary team at the University of Connecticut, led by two veteran pharmaceutical researchers, helps health care professionals make better-informed decisions by sifting through the latest research to recommend the best treatment options based on a strict analysis of the scientific evidence.

The AHRQ's EPC paradigm is also taking hold overseas. From the National Institute for Health and Care Excellence, which provides national guidance and advice to improve health and social care in the United Kingdom, to hospital-based health technology assessment centers that use a multidisciplinary approach to answer relevant questions regarding the safety, efficacy, effectiveness, and cost-effectiveness of health technologies, there's growing interest in implementing evidence-based practices at the national and hospital levels to facilitate better decision making.

"The development of infrastructures to support evidence-based practices across the country and the globe is a matter of time and evolution," Umscheid says. "There may very well be activities at other institutions where they conduct evidence reviews to inform decision making, but it's likely less formal, not as systematic, and may lack the reach beyond an individual department or committee."

Setting Guidelines for Treatment and Care
Umscheid says the Centers for Medicare & Medicaid Services uses reports generated by AHRQ EPCs to help make health coverage decisions that affect millions of patients. In addition, national medical, nursing, and pharmacy organizations lean on the reports to set treatment and care guidelines.

At the hospital level, EPCs influence various segments. "The activities of our hospital EPC at Penn are focused on addressing the questions of clinical and administrative leaders across our health care system, whether they need help finding answers that can inform a decision they are making or want to know best practices for addressing a given problem across clinical units or service lines," Umscheid says. "Whether the question involves removing a drug from formulary if evidence shows it can be harmful or determining whether certain supplies or devices are the best ones to purchase for a particular indication, our rapid synthesis of evidence can make a difference."

Umscheid believes medical societies, particularly those in the United States, better understand the value of evidence syntheses and how formal processes to review and weigh evidence can help improve the rigors of their clinical guidelines. He suggests that extrapolating that thinking down to the hospital level truly highlights this. "I think the most important part of our study is this idea that you can have a centralized center within a health care provider organization doing this type of work, not just within a medical society or government," Umscheid notes. "At some level, this is a proof-of-concept study that suggests that if you create such a hospital evidence-based practice center, there will be a need for it, its reviews will be used to inform institutional decision making, and requestors will find the information helpful, readable, and reliable."

Future Prospects
Umscheid says more national reviews should be adapted for local settings, and hospital EPCs, as well as EHRs, can help make that a reality. For example, EPCs can mine local data from an EHR to answer questions and solve problems brought to them by hospital leaders. According to Umscheid, hospital EPCs can use EHR data to perform the following functions:

• define a problem's scope;

• determine whether an implemented solution has affected outcomes; and

• implement solutions on the front end.

Organizations interested in establishing an EPC need not take a deep dive, Umscheid says. "People often ask me how they can start a hospital EPC in their own institution and I always tell them that I believe even if it's a tiny group, merely one clinician with some expertise in evidence-based practice who spends part of their time doing this work, they can accomplish a lot," he says. "If they are successful in what they do and handle a lot of requests, the institution just might find a reason to grow that group, particularly if it impacts value-based purchasing decisions or meaningful use incentives."

Umscheid says most health care organizations are realizing the importance of having a dedicated group of experts who can synthesize evidence to adapt national guidelines to their local setting. It's just a matter of knowing where to start.

— Amanda Griffith is a freelance writer in southeastern Massachusetts.