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2004 Vohs and Lawrence Awards; A Focus on Evidence-Based Medicine |
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The
Care Management Institute: Making the Right Thing Easier to Do |
to
pdf >> The Kaiser Permanente (KP) Care Management Institute's (CMI) defining mission is "Making the Right Thing Easier to Do," and for almost eight years, CMI has emphasized both developing the credible knowledge base (the "right thing") and operationalizing it (the "doing"). A thorough grounding in the science of medicine is absolutely necessary in clinical practice, but it is not in itself sufficient. Building the bridge between clinical research and practical clinical application for patients--combining evidence-based medicine with evidence-based management--is at the heart of Permanente Practice. It is for this reason that CMI cosponsored the Evidence-Based Medicine Symposium last December. The creation of rigorous, evidence-based clinical content is the foundation of CMI's work. Interregional workgroups consisting of clinical experts from medicine, pharmacy, and nursing, evidence-based methodologists, and CMI care management consultants have created clinical practice guidelines for a core set of conditions and health care issues: asthma, coronary artery disease, chronic pain, cancer, depression, diabetes, elder care, heart failure, and self-care and shared decision making. These guidelines have been approved on a national level by the National Guideline Directors, representing all regions, and are revised at least every two years. Guidelines, associated care management programs, and clinicians and patient tools are made available to clinicians in a variety of print formats, including full-length technical and summary documents, as well as on the Clinical Library (CL) (Available at: http://cl.kp.org). CMI also is leading an interregional effort to ensure the availability of this high-quality, evidence-based knowledge within KP HealthConnect as decision support. With this robust knowledge base in place, CMI has also been focusing efforts on how to practice evidence-based management--taking the medical knowledge base, "diffusing" the knowledge to all regions, and making it used and useful to clinicians in their work-a-day lives. One example is the KP Improving Performance Project, which was initiated at the request of the CMI Board of Directors in order to: 1) understand more fully what underlies persisting differences in performance of key clinical interventions across operational sites, and 2) develop strategies for operational leaders to use to better understand and thereby reduce this variation. The project is initially looking at the management of members with diabetes, asking: What organizational practices are associated with superior outcomes in diabetes care? Factors accounting for regional performance variations were investigated by conducting regional and medical center surveys examining the level of implementation of specific operational practices, such as the use of alerts and reminders or the ability to create an action plan with a member. Survey results were linked to diabetes outcomes measures from across the Program to identify potential relationships between these practices and high performance. In the first phase of analysis certain practices stand out: action plans, alerts and reminders, physician financial incentives tied to diabetes clinical quality measures, capability and capacity for inreach and outreach to members, and the presence of a fully automated health record. CMI is using the findings from this study to: 1) focus further investigation of operational practices associated with high performance, 2) integrate the findings with implementation of KP HealthConnect as appropriate, and 3) support regional improvement efforts. To further clarify the relation between organizational practices and performance, CMI sponsored a series of focused case studies of specific high- and lower-performing sites in conjunction with the Harvard Business School. A key challenge for KP, as it is for the rest of health care, is the rapid and thorough spread of effective new ideas and practices. The ALL (aspirin-lovastatin-lisinopril) Project is an example of how KP is improving in this important area. The HOPE trial1 and the Heart Protection Study2 showed that the combined effect of three groups of medications can immediately reduce the risk of heart attack and death by at least 25% for members with diabetes or coronary artery disease. Aspirin, lipid-lowering statins, and angiotensin converting enzyme inhibitors (ACE-I) or angiotensin receptor blockers (ARB) are close to being magic bullets in the fight against cardiovascular disease. The potential impact of these three medications on health care outcomes and costs was projected using Archimedes, a KP computer-simulation model and the brainchild of Leonard Schlessinger, PhD, and David Eddy, MD, PhD. According to Archimedes modeling, appropriate pharmacotherapy over ten years for just 10,000 KP members with coronary artery disease would result in 4063 avoided heart attacks, 893 avoided deaths, and more than $44 million saved. With this evidence in hand, CMI and the KP regions began working to ensure that every KP member who can and should take these medications does so. CMI convened a series of quarterly interregional teleconferences to focus on regional strategies for improving ALL usage. By providing a mechanism for diffusing successful regional practices for starting an ALL regimen, CMI aimed to maximize innovation and reduce programmatic trial and error. The goal was to shorten the interval until every KP member at risk for an adverse cardiovascular event benefits from the protective effect of these medications. Regions have been doing groundbreaking, innovative work with high levels of commitment and creativity to increase ALL use. Regions use a combination of strategies to increase risk-reducing pharmacotherapy, including identifying and reaching out to members at risk, setting quality goals, and relying on clinical champions to spread the word about the importance of ALL. A final word: Evidence-based medicine and evidence-based management are tools which, when appropriately used, can support the right things being done for the right person at the right time. They will, however, necessarily remain tools that ultimately must be put to good use by clinicians and members using evidence, judgment, and experience, to provide great care. References
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