Current issues of ACP Journal Club are published in Annals of Internal Medicine


Editorials

Evidence-based medicine at the Agency for Health Care Policy and Research

ACP J Club. 1998 Mar-April; 128:A12. doi:10.7326/ACPJC-1998-128-2-A12



The U.S. Agency for Health Care Policy and Research (AHCPR) was established in 1990 to generate and disseminate information that improves the delivery of health care. The AHCPR pursues this mission through a broad range of intramural and extramural activities: research on the quality, outcomes, organization, and costs of health care; support for training programs in health services research; and dissemination of information to allow clinicians and patients to make informed health care decisions.

Translating up-to-date information into better medical care is central to the broad international movement commonly known as "evidence-based medicine" (1), and several AHCPR programs have been closely identified with evidence-based medicine in the United States. The Medical Treatment Effectiveness Program (MedTEP) funds research on the effectiveness, cost-effectiveness, and appropriateness of clinical interventions. Among its best-known projects has been the establishment of Patient Outcome Research Teams (PORTs), which are multidisciplinary research groups that assess the effectiveness of diagnostic services and treatments for common, high-cost conditions (2). The AHCPR has funded 25 PORTs to study such conditions as prostate and gallbladder disease, cataracts, and pneumonia. PORT studies have yielded important new information on geographic variations in health care; the benefits, risks, costs, and cost-effectiveness of diagnostic and treatment options; and patient preferences.

The AHCPR's Clinical Practice Guidelines Program also helped galvanize interest in evidence-based methods to assess medical treatments by frequently building on information developed by PORT projects. Between 1990 and 1996, AHCPR-supported panels produced 19 clinical practice guidelines, including both clinician and patient materials, on the diagnosis and treatment of common clinical disorders, such as urinary incontinence, heart failure, and otitis media. These guidelines have been widely circulated and implemented by many health plans, hospitals, and other health care organizations (3). Equally important, the AHCPR program set high standards for the development of guidelines, including the involvement of multidisciplinary panels and the use of an explicit, evidence-based approach (4). We learned some lessons in the process. However, convening separate national panels to develop each guideline was relatively expensive and time-consuming, the final products were often modified by users to fit local conditions, some clinicians perceived individual guidelines as a threat to their clinical autonomy, and the demand for evidence-based information far exceeded the resources we could devote to guidelines.

Rapid and profound changes in the health care market and the evolving needs of the medical community and public have broadened the audience for reliable, up-to-date evidence about medical treatments. Spurred by enthusiasm for clinical practice guidelines as a means of encouraging the most effective and efficient medical care, professional societies, health plans, and commercial firms have generated thousands of guidelines. Although the quality of these products varies, a growing number of organizations (5-7) have begun to develop guidelines based on more systematic reviews of the evidence of benefits and harms in place of previous approaches that relied primarily on the consensus of small groups of experts.

Evidence is also important to employers and insurers. Health systems increasingly rely on results of technology assessments to help resolve difficult decisions about what new treatments and technologies should be adopted (8). Patients now have access to a wide range of medical information in the media and on the Internet, but they still need to be sure that the information obtained is unbiased and based on the best available evidence.

As consumers, patients, health plans, systems of care, and purchasers seek more information on medical care, the AHCPR has worked to identify where it can be most valuable. Because the knowledge base for these decisions is an essential public good, government involvement can assure that the scientific foundation for various treatments and technologies is sound and ensure that such information remains widely available. The quality of many assessments of medical treatments and technologies is all-too-often incomplete, outdated, or colored by self-interest, and few groups have the resources to analyze hundreds or thousands of studies to determine the balance of risks, benefits, and costs of specific tests and treatments.

Government can also serve as a credible, neutral party that promotes cooperation among competing organizations. The broad consensus that emerged in the recent guidelines on colorectal cancer screening (9) owes much to the variety of medical specialists and nonphysicians assembled by the AHCPR to review the scientific evidence.

In an effort to fulfill its missions while maximizing limited resources, the AHCPR recently announced its Evidence-based Practice Centers (EPCs) program as the logical successor to its guidelines activities. Having established high standards for the development of guidelines, the AHCPR recognizes that many health plan administrators, members of professional societies, and other concerned individuals are now adopting similar standards. Many organizations, however, do not have the resources to critically appraise, synthesize, and translate the existing evidence into information that can be used to develop guidelines, to design educational programs, or otherwise to improve clinical practice and decision making. Therefore, the AHCPR has created the EPC program to produce "evidence reports" on selected topics—that is, careful analyses that can be used to develop guidelines, performance measures, educational materials, and other quality improvement programs. The 12 EPCs represent a mix of academic institutions and private organizations with national and international reputations for their work on systematic reviews, meta-analysis, and technology assessment (Table).

A key feature of this initiative is public-private partnerships between the AHCPR and various professional societies, health plans, patient and provider groups, and other state and federal agencies (Table). These outside organizations nominate potential topics, help identify the critical clinical questions, and provide expert input to the Centers. Most important, partners will translate the summarized evidence into clinical policy, because evidence reports will not include specific recommendations for clinical care. These partners are often in the best position to understand how to use the evidence to devise practical strategies for improving care.

The EPC initiative is an opportunity for partnership with the Cochrane Collaboration. Cochrane review groups have undertaken the daunting task of developing systematic overviews of all published and unpublished randomized controlled trials (RCTs) of treatment effectiveness (10). All 5 North American Cochrane Centers are involved directly or indirectly with the AHCPR's EPC program. The EPC projects will, however, extend beyond the Cochrane focus on RCTs. Depending on the topic, evidence reports are likely to consider a broad range of other data to assess diagnostic strategies, side effects of treatments, patient preferences, and cost-effectiveness of different treatment options. The EPCs will also provide support to the U.S. Preventive Services Task Force, which is being reconvened under the aegis of the AHCPR to update its assessments of preventive services, including screening tests and clinician counseling (11). The initial set of topics assigned to the EPCs also includes reviews that will assist other government activities, including several planned National Institutes of Health Consensus Development Conferences and technology assessments requested by the Health Care Financing Administration.

Once guidelines are written, effective dissemination remains a challenge. No easy way exists for the typical patient, physician, or plan to obtain the best guidelines or to understand areas of agreement and disagreement among similar guidelines. To address this need, a public-private partnership between the AHCPR, the American Medical Association, and the American Association of Health Plans will support a National Guideline Clearinghouse that provides online access to a wide array of clinical guidelines and syntheses of guidelines. The Clearinghouse is now being planned and is expected to be operational in September 1998.

Other AHCPR initiatives seek to improve the evidence base for measuring health care quality. For example, the Quality Measurement Network represents a partnership with the leading national quality organizations (the Foundation for Accountability, Joint Commission on Accreditation of Health-care Organizations, and National Committee for Quality Assurance) to develop a publicly available national database of clinical performance measures that can be used by hospitals, health plans, and provider groups in support of quality improvement programs.

Finally, ongoing research programs will encourage collaboration among health plans and provider groups to identify the most effective ways to help clinicians stay abreast of advances in knowledge and to improve the effectiveness of their clinical practices. As proponents of evidence-based medicine recognize, better information is only the first step to improving health care quality. Equally important are understanding the gaps between the evidence and current practice and how to bridge those gaps. To cite one of many examples, a recent AHCPR-funded study found that β-blockers were prescribed to fewer than 1 in 5 elderly patients after myocardial infarction and that underuse of this effective treatment contributed to a higher mortality rate (12). Research on the most effective ways to implement evidence-based interventions in different settings with different populations can help narrow the gap between efficacy and effectiveness.

As a publicly funded agency, the AHCPR must subject its actions to the same scrutiny it advocates for medical treatments and technologies. An ongoing challenge is to develop reliable evaluation methods to ensure that its research addresses the most critical issues affecting the quality of care, that results from such research have a measurable impact on practice and outcomes, and that the information and tools made available meet the needs of varied constituents. The systematic analyses produced by the EPCs will provide a map of individual paths toward better health care. The AHCPR's research on implementation, outcomes, and quality measurement and improvement, in turn, provides a basis for choosing specific routes on that map and provides tools for measuring progress. Evidence-based methods will ensure that all of us have a map that is readable and reliable to guide us toward our destination of better health care for all.


References

1. Sackett DL, Richardson WS, Rosenberg W, Haynes RB. Evidence-Based Medicine: How to Practice and Teach EBM. New York: Churchill Livingstone; 1997.

2. Agency for Health Care Policy and Research. PORT and PORT-II Abstracts. Rockville, MD: Agency for Health Care Policy and Research, 1997 (AHCPR Pub. No. 97-R017).

3. AHCPR-sponsored guidelines help users increase quality and cut costs. Agency for Health Care Policy and Research, Rockville, MD. Research Activities, 194:10-1, Jun 1996.

4. Berg AO, Atkins D, Tierney W. Clinical practice guidelines in practice and education. J Gen Intern Med. 1997;12(Suppl 2):S25-S33.

5. Centers for Disease Control and Prevention. CDC guidelines: improving the quality. Atlanta: Centers for Disease Control and Prevention; 1996.

6. Middleton RG, Thompson IM, Austenfeld MS, et al. Prostate Cancer Clinical Guidelines Panel summary report on the management of clinically localized prostate cancer. The American Urological Association. J Urol. 1995;154:2144-8.

7. American Psychological Association, Task Force on Psychological Intervention Guidelines. Template for Developing Guidelines: Interventions for Mental Disorders and Psychosocial Aspects of Physical Disorders. Washington, DC: American Psychological Association; 1995.

8. Steiner CA, Powe NR, Anderson GF, Das A. The review process used by US healthcare plans to evaluate new medical technology for coverage. J Gen Intern Med. 1996;11:294-302.

9. Winawer SJ, Fletcher RH, Miller L, et al. Colorectal cancer screening: clinical guidelines and rationale. Gastroenterology. 1997; 112:594-642.

10. Bero L, Rennie D. The Cochrane Collaboration. Preparing, maintaining, and disseminating systematic reviews of the effects of health care. JAMA. 1995;274:1935-8.

11. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services, 2nd ed. Baltimore: Williams and Wilkins; 1996.

12. Soumerai SB, McLaughlin TJ, Spiegelman D, et al. Adverse effects of underuse of beta-blockers in elderly survivors of acute myocardial infarction. JAMA. 1997;277:115-21.




Table. The Agency for Health Care Policy and Research's Evidence-based Practice Centers and their public-private partnerships

Topic (Nominator) Evidence-based Practice Center
Pharmacotherapy of alcohol dependence American Society of Addiction Medicine Research Triangle Institute/University of North Carolina, Chapel Hill, NC
Assessment and treatment of stable angina American College of Cardiology/American Heart Association Task Force on Practice Guidelines University of California, San Francisco, CA, and Stanford University, Palo Alto, CA
Diagnosis and management of sleep apnea Blue Cross/Blue Shield of Massachusetts, Sleep Disorders Centre of Metropolitan Toronto MetaWorks, Inc., Boston, MA
Treatment of attention deficit/hyperactivity disorder American Academy of Pediatrics, American Psychiatric Association McMaster University, Hamilton, ON
Treatment of traumatic brain injury National Institute of Child Health and Human Development Oregon Health Sciences University, Portland, OR
Androgen suppression for prostate cancer Health Care Financing Administration Blue Cross/Blue Shield Association, Chicago, IL
Evaluation of abnormal cervical cytology American College of Obstetricians and Gynecologists Duke University, Durham, NC
New pharmacotherapies for treatment of depression National Institute of Mental Health, American Psychiatric Association, American Pharmaceutical Association, Vermont Department of Mental Health/Mental Retardation, Blue Cross/Blue Shield of Massachusetts University of Texas at San Antonio, San Antonio, TX
Diagnosis and treatment of dysphagia/swallowing problems in the elderly Health Care Financing Administration ECRI (Emergency Care Research Institute), Plymouth Meeting, PA
Management of new onset atrial fibrillation in the elderly American Academy of Family Physicians Johns Hopkins University, Baltimore, MD
Prevention and treatment of secondary complications of paralysis Paralyzed Veterans of America (including 30 local chapters), American Association of Spinal Cord Injury Psychologists, American Congress of Rehabilitation Medicine, American Paraplegia Society, Association of Rehabilitation Nurses, Consortium for Spinal Cord Medicine Southern California Evidence-based Practice Center-RAND, Santa Monica, CA
Diagnosis and treatment of acute sinusitis American Academy of Otolaryngology, American Academy of Pediatrics New England Medical Center, Boston, MA