••Spring 2005/Vol. 9, No. 2

Health Systems

Balance Sheets: Tools to Inform Changes in Practice | to pdf >>
By Matt Handley, MD

Balance Sheets--Tools for Translating Evidence into Practice

Integrated care delivery systems have two inherent advantages over other health care organizations. First, we integrate the financing of care with care delivery. Second, our integrated care delivery systems position us to be able to collaboratively recommend and carry out changes in practice more effectively than other delivery systems. The ability to change practice comes with responsibility. We need to understand the value of a change in clinical practice--the improvement in outcomes for the resources expended--to be effective stewards of our patients' health care resources. Because the decision to work together to change practice should be considered an opportunity cost, we need tools to understand the relative value of different clinical initiatives to focus our resources for change wisely.

Turning Evidence into Guidance

At its core, evidence-based medicine (EBM) has a systematic approach to understanding the difference in clinical outcomes for different clinical strategies. Posing a clinical question, systematically searching for evidence to answer that question, and critically appraising the evidence are the foundation of EBM. The practical tools that help us translate evidence in practice are evidence-based guidelines.¹ We all face many of the same clinical questions every day, and guidelines help us leverage our group's collective clinical wisdom with scientific rigor to help inform the choices we make with individual patients every day. It is more than "treatment A is more effective than treatment B"--it includes a quantitative estimate of how much better A is than B. Understanding the benefits, harms, and cost of different clinical strategies allows us to grapple with the value equation. The tool that ensures that evidence-based guidelines deliver not just improved outcomes, but also value, is the balance sheet.

David Eddy, MD, PhD, pioneered the use of balance sheets in clinical guideline development work.² He has described them as a tool to: 1) estimate the health and economic outcomes from clinical research and clinical experience, 2) assist decision makers to develop an accurate understanding of the important consequences of adopting the different options, 3) condense important information into a space that can be grasped visually and mentally at one time, and 4) assist in planning organizational change (eg, organize thinking, structure the analysis of evidence, and focus debates).

A balance sheet takes evidence to the next step by comparing the outcomes of different clinical strategies. A good balance sheet includes clinical outcomes (eg, myocardial infarction, death, symptomatic improvement), utilization outcomes (eg, laboratory tests ordered, prescriptions, visits) and overall system costs.³ Although patient satisfaction is an extremely important outcome, it is so confounded by service-related issues (eg, time spent waiting for the doctor, phone access) that modeling effects on satisfaction is rarely helpful. Assumptions always must be made--we never have perfect evidence. Assumptions should be explicit and vigorously questioned--and especially where the evidence is not strong. For most clinical conditions, the balance sheet should consider the Venn diagram of the health care delivery system rather than a societal perspective, with timeframes tied to the duration of the anchoring clinical trials that provide the evidence of clinical benefit.

Balance sheets are challenging. A small number of people in the program have the skills both to construct them and to help teams to use them for making decisions. Balance sheets provide an opportunity for analysis paralysis--adding complexity is often a strategy to postpone decision-making. They often help bring to the surface differences in how individuals value different outcomes, challenging (but also moderating) advocacy positions.

Turning Guidance into Practice

In addition to helping inform guideline development, balance sheets contribute important information to help plan implementation.⁴ They provide quantitative estimates of the impact of implementation on our delivery system. They help make sure that we are practical in our recommendations and operate within the resources we have available to help our patients. Planning implementation using a balance sheet helps ensure that the resources that we invest in changing practice are commensurate with the improvement in clinical outcomes that we expect for our patients.

Balance sheets also hold another promise: better information to inform the decisions that we make with our patients every day. Shared decision-making isn't possible without a personal balance sheet--an estimate of the likelihood of clinical outcomes with different choices in practice. As we work to develop tools to change practice, we must continue to increase the sophistication of the tools that directly support a patient's personal decision-making process.

Balance sheets do not make decisions--they inform decisions. They are the critical tool that helps inform our decisions as we grapple with difficult trade-offs in marginal benefit. Our ability to grapple, together with our ability to make tough decisions and the ability to act on our decisions, sets us apart from other health care organizations and will help us make purposeful decisions to deliver on our promise to all of our customers--our patients, our provider community, and our purchasers.

References

1. Eddy DM. Comparing benefits and harms: the balance sheet. JAMA 1990 May 9;263(18):2493, 2498, 2501 passim.
2. 2Handley MR, Stuart ME. An evidence-based approach to evaluating and improving clinical practice: guideline development. HMO Pract 1994 Mar;8(1):10-9.
3. Braddick M, Stuart M, Hrachovec J. The use of balance sheets in developing clinical guidelines. J Am Board Fam Pract 1999 Jan-Feb;12(1):48-54. Erratum in: J Am Board Fam Pract 1999 Mar-Apr;12(2):187.
4. Handley MR, Stuart ME, Kirz HL. An evidence-based approach to evaluating and improving clinical practice: implementing practice guidelines. HMO Pract 1994 Jun;8(2):75-83.

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