Category Archives: Evidence-based
David S. Jones, MD, PhD, is the A. Bernard Ackerman Professor of the Culture of Medicine at Harvard Medical School's Department of Global Health & Social Medicine. He is a 2007 recipient of a Robert Wood Johnson Foundation (RWJF) Investigator Award in Health Policy Research, and the author of Broken Hearts: The Tangled History of Cardiac Care.
Every day, all over America, people visit their doctors with chest pain and other symptoms of coronary artery disease. Each year, more than a million of them choose to undergo bypass surgery or angioplasty. Are these decisions good ones? Even though modern medicine has committed itself to an ideal of evidence-based medicine, with its clinical trials, meta-analyses, and practice guidelines, the answer is not always clear. By looking closely at the history of these procedures, it is possible to understand some of the reasons why this is the case. With support from a RWJF Investigator Award in Health Policy Research, I looked at three specific questions: the role of evidence and intuition in medical decisions, the reasons why it can be so difficult to determine the risks of medical interventions, and the problem of “unwarranted variation” in medical practice.
This is part of the June 2013 issue of Sharing Nursing's Knowledge.
“Not a week goes by that I don’t receive at least one letter from a patient or family member grateful for the extraordinary care he or she received from a nurse. Using descriptions such as ‘tireless,’ ‘compassionate,’ ‘gentle’ and ‘efficient,’ these gifts from the heart speak volumes about a profession we celebrate throughout May that is the heart and soul of our nation’s health care delivery system. And while National Nurses Month is a time for gratitude and celebration, it is important to remember that the New Jersey nursing profession faces significant challenges that must be overcome ... Sometime this month, thank a nurse. It means much more than you realize.”
-- Robert P. Wise, FACHE, president and chief executive officer, Hunterdon Healthcare, Take a Moment to Thank a Nurse During National Nurses Month, Times of Trenton, May 21, 2013
“Growing up, I thought I would become a doctor, but then I met my wife, an RN [registered nurse], and I fell in love with her—and with her career. I’m thrilled with my professional decisions; I find great joy in helping my patients recover and my students learn. I’m able to combine my love of nursing practice and education because NJNI [the New Jersey Nursing Initiative] put me on a fast track to a master’s degree in nursing ... NJNI helped me re-imagine my future. I now see myself as an emerging nurse leader and plan to enroll in a doctorate program in the fall to realize that vision.”
-- Marlin Gross, MSN, APN, NP-C, New Jersey Nursing Scholar, assistant professor, Cumberland County College and family nurse practitioner, Virtua Health Care System in Marlton, Remember What Nurses Do for Us Every Day, Daily Journal, May 15, 2013
The Robert Wood Johnson Foundation (RWJF) Interdisciplinary Nursing Quality Research Initiative (INQRI) will host a webinar on January 31, 2013 as part of a series featuring all of the INQRI's grantee teams focused on translating research into practice. The webinar will feature INQRI Investigators Susan Beck, PhD, APRN, FAAN, and Nancy Dunton, PhD, FAAN, discussing their research on dissemination and implementation of evidence-based methods to measure and improve pain outcomes.
The webinar will be held from 2-3 p.m. EST.
Robin Newhouse, PhD, RN, is a grantee of the Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative. She is professor and chair, Organizations Systems and Adult Health at the University of Maryland School of Nursing. She is also vice-chair of the Methodology Committee for the Patient-Centered Outcomes Research Institute. This post is part of the "Health Care in 2013" series.
My resolution for the U.S. is to begin the transformation of health care systems to enhance high quality patient-centered care. Despite some improvements, the National Healthcare Quality Report 2011 reveals that health care quality in the U.S. often falls short of expectations—demonstrating geographic and population (minority and low-income) variations. In 2011, the U.S. Department of Health and Human Services (HHS) released the National Quality Strategy (NQS), designed to improve the quality of health care in the U.S. My highest priority for action is the first aim: “Better Care: Improve the overall quality of care, by making health care more patient-centered, reliable, accessible, and safe.” Better care is achievable—with two specific strategies in mind: implementation of evidence-based practices and a focused goal to measure and improve patient-centered outcomes.
Implementation of Evidence-Based Practices. We have not gone far enough, fast enough. It is time to focus on implementation of evidence-based practices in health care systems. Research studies have continued to exponentially produce results intended to inform health care practices. Identifying and implementing evidence-based practices known to work—but that are underutilized—can go a long way to improve health care processes and quality. Performance measures are an example of one approach to drive system changes. The 2012 NQS Annual Progress Report describes the achievements of the first year’s work, including a focus on clinical and patient-reported outcomes (as close as possible to patient-centered) and development of new patient-centered outcomes.
Recently, Nurse.com covered a new study conducted by Bernadette Melnyk, PhD, RN, CPNP/PMHNP, FNAP, FAAN. Published in the September issue of the Journal of Nursing Administration, the study of more than 1,000 registered nurses found that resistance from nursing leaders and other barriers prevent nurses from implementing evidence-based practices, even when those practices could improve patient outcomes.
In a recent post for the American Journal of Nursing’s Off the Charts blog, Mary Naylor, PhD, FAAN, RN, program director for the Robert Wood Johnson Foundation’s Interdisciplinary Nursing Quality Research Initiative (INQRI) program, weighed in on the topic, discussing the complexities of today’s health care system. Naylor noted that, “administrative and workflow inefficiencies limit hospital nurses from spending more than about 30 percent of their time on direct patient care.”
Given the challenges and barriers noted by Melnyk and the limited amount of time that nurses actually get to spend with patients, how can nurses influence the delivery of evidence-based practices? Project investigators from the INQRI program commented on some of the challenges associated with translating research into practice.
Barbara Resnick, PhD, CRNP, FAAN, FAANP, professor at the University of Maryland School of Nursing, notes that “there is a well-known lag in the implementation of evidence-based findings into real world clinical settings with the average length of time from discovery of a drug intervention, for example, to implementation into practice taking approximately 13 years.”
“Similarly,” Resnick notes, “there continue to be individuals who do not benefit from simple and well established interventions such as pneumonia vaccines or exercise interventions. Currently there is a need to better understand the effectiveness of dissemination and implementation approaches and the science that underlies implementation research. It is only in this manner that we will truly change care at the bedside.”
Last week, the Robert Wood Johnson Foundation (RWJF) and The Alliance for Health Reform sponsored a briefing to discuss oral health care in the United States, particularly for children and other vulnerable populations.
The discussion was co-moderated by David Krol, MD, MPH, FAAP, RWJF Human Capital Portfolio team director and senior program officer. “Oral health is an integral part of overall health,” he said. It faces the same challenges as overall health care, including “racial, ethnic, geographic disparities in disease and access to care, financing challenges, issues of determining and maintaining quality of care, and workforce controversies.” Krol said he would like to see “all conversations on health and health care… naturally include oral health.”
In 2009, preventable dental conditions accounted for more than 830,000 emergency department visits nationwide, Julie Stitzel, MA, of the Pew Center on the States’ Children’s Dental Campaign told the audience. Children were the patients for 50,000 of those visits. “There’s a real opportunity for states to save money because these visits, again, are totally preventable,” she said. “We know that getting treated in an emergency room is much more costly than the care delivered in a dental office, and states are bearing a significant share of these expenses through Medicaid and other public programs.”
By Craig Pollack, MD, MS, MHS, a Robert Wood Johnson Foundation/U.S. Department of Veterans Affairs Clinical Scholar alumnus (2006-2009), assistant professor of medicine and associate director of the General Internal Medicine Fellowship program at Johns Hopkins University
The United States Preventive Services Task Force, a group never to shy away from controversy, recently released its final recommendations on prostate cancer screening. The Task Force gave prostate-specific antigen (PSA) testing a grade D, indicating that it should be discouraged as part of routine testing. They noted that there were substantial harms associated with testing and subsequent diagnosis and treatment: worry and anxiety; infections from biopsies; incontinence and erectile dysfunction. And the benefits were likely to be small—on the order of 1 life saved for every 1,000 men screened.
However, the recommendations have caused tremendous controversy. Critics question whether the Task Force has appropriately weighed the risks and benefits and balanced the existing evidence. Our research suggests that even those who agree with the recommendations will find it hard to stop screening. We are now working on a set of decision-making tools for primary care providers (PCPs) and patients to minimize unnecessary screening.