Hard Evidence

TMA Collaborates With AHRQ on Evidence-Based Decisionmaking Tools

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Quality Feature — June 2014

Tex Med. 2014;110(6):49-52.

By Amy Lynn Sorrel
Associate Editor

Lisa Ehrlich, MD, often finds the same questions routinely come up with her patients, whether they face a new diabetes diagnosis or have managed their particular condition for a while and ask about availability of new drugs. Even though the Houston internist is generally up to date on the latest research, she can't always find it in one place. Nor is a 15-minute office visit always enough time to answer all of her patients' questions, especially if they need time to digest the information and make a treatment decision. 

With help from the Agency for Healthcare Research and Quality's (AHRQ's) Effective Health Care Program, however, Dr. Ehrlich has a new tool that puts evidence-based research on diabetes treatments and a host of other diseases at her fingertips. Without having to sift through dozens of PubMed articles, she can read a quick clinical summary of the comparative safety and efficacy of available diabetes medications. If a patient thinks he should be on testosterone replacement therapy after hearing about it anecdotally, she can point him directly to the evidence summarized in a patient-friendly brochure. 

"From a quality standpoint, evidence-based decisionmaking is one of our top priorities. It's valuable to patients' health, to quality of care, and even to physicians' economic viability. We want to make sure we are putting our resources where they are most effective," said Dr. Ehrlich, chair of the Texas Medical Association Council on Health Care Quality.  

The program not only helps to improve physicians' access to evidence-based sources, but it also helps doctors deliver that information to their patients, adds Frank J. Villamaria, MD. The Temple anesthesiologist is a member and past chair of TMA's quality council and past medical director for quality at Scott & White Healthcare, now Baylor Scott & White Health.

"Patient engagement is a fundamental premise of quality, and this [program] takes it to the next level," he said. "In most cases, this information supports what doctors already know. But it allows them to explain it in a way that supports what they are advocating to the patient." 

Like Choosing Wisely, the Effective Health Care (EHC) Program is part of a growing national effort to empower physicians and patients with reliable tools to promote shared and informed health care decisions.

"We are trying to facilitate even more those conversations and channel these kinds of resources to the benefit of Texas physicians. Helping our physicians treat patients more effectively and making that process easier: That's the goal," Dr. Villamaria said. 

Effective Tools, Effective Care

That’s why TMA is collaborating with AHRQ's EHC Program to put free, evidence-based resources directly into physicians' and patients' hands. TMA is a member of the program's National Partnership Network, and the tools are the latest in a suite of quality improvement resources the association's Council on Health Care Quality has developed or collaborated on with other organizations. For more information, visit the TMA website

With the EHC Program, AHRQ collects and summarizes the findings of published and unpublished scientific research on the effectiveness, benefits, and risk of treatment options for a variety of chronic health conditions: type 2 diabetes, cardiovascular disease, obesity, pregnancy, mental health, and digestive system conditions, among others. 

The agency then translates those findings into evidence-based tools and materials that include physician- and patient-friendly research summaries and patient decision aids. 

The diabetes and cardiovascular disease research summaries are immediately available and downloadable at no cost through TMA's website. There, doctors can view and print free treatment summaries for themselves and their patients or order them in bulk. They also can link directly to patient videos explaining what it means to be newly diagnosed and how to evaluate treatment options, for example. (While TMA considers expanding the menu of health conditions, free summaries and evidence-based tools for other conditions, as well as continuing medical education activities and more information on the Effective Health Care Program, are available through AHRQ's website.)

The physician summary on high blood pressure medications, for example, not only provides a succinct "clinical bottom line" on the benefits and adverse effects of angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), or a direct renin inhibitor (DRI) for adults with hypertension, but also indicates the strength of the research behind each treatment. Physicians can see a summary of the gaps in knowledge and directly link to the research sources AHRQ used to draw conclusions like, "There is high strength of evidence that ACEIs and ARBs control blood pressure to a similar extent. Data are limited for comparisons involving the DRI aliskiren."  

The companion patient brochure offers similar information that's easy to understand, including background on high blood pressure, why it's important to take the medications as prescribed, and a list of questions patients can discuss with their physicians on topics such as costs or other medicines they take. 

Getting It Right

AHRQ Medical Officer Supriya Janakiraman, MD, says the ultimate goal of the EHC Program she helps oversee is to improve quality and efficiency in health care. It focuses on comparative effectiveness research: "By identifying and knowing what works, and more importantly what doesn't work, this will help to improve decisionmaking and outcomes, and ultimately improve the quality of the care delivered."

To accomplish that, AHRQ assembles reports and parses research based on what Dr. Janakiraman calls "real-world situations." For example, a number of studies on gout management take place in a research center where patients have rigorous monitoring and follow-up to make sure they adhere to their treatment regimen. But such conditions typically don't mimic patients' day-to-day lives, often filled with comorbidities and busy schedules. 

"We take that into account in terms of the types of reports we fund and the studies we look at during a systematic review," she said. "Young healthy volunteer subjects might not be the reality of the average patient sitting in front of you. Doctors really want to know if the findings they see in the headlines are applicable to their patients." 

That's also why physicians, patients, and anyone from the general public can submit topics for AHRQ to research, says Dr. Janakiraman, who also oversees the program's selection process through the agency's Evidence-based Practice Center. "We want to make sure we are asking the right questions about where the clinical uncertainty is with respect to management, treatment options, and monitoring," he said.

AHRQ convenes a group of experts to home in on and answer those clinical questions. The Evidence-based Practice Center, for example, evaluates the quality of the available research, which physicians can see on a "strength of evidence scale" displayed on a clinician summary. Throughout the process, the center also relies on subject-matter experts, including physicians, who understand the nuances of a particular condition, to develop the topics and create and peer-review the summaries. 

"If we get the questions wrong or the methodology is inaccurate, nobody will use these reports. So we hope that by engaging not only physicians, but also patients, early on in the process and frequently, we create something that quite frankly will be useful in their day-to-day decisionmaking," Dr. Janakiraman said.

The California internist added that some medical specialty societies, including the American College of Physicians, have used the information to inform their clinical guidelines development. 

But the reports are not treatment recommendations, Dr. Janakiraman insists. 

"We review what's known and not known and outline the benefits and harms. And the idea is to couple that with the provider's own expertise and patient preferences," she said. "We understand this is just one tool physicians can use to inform their decisionmaking, and this is in no way meant to replace their clinical judgment." 

Maximizing Physicians' Time

TMA's Council on Health Care Quality members say the EHC Program can really help maximize physicians' precious time. 

"I can spend just a few minutes looking at the bullet points, or if I have more time, I can drill down into the evidence," Dr. Ehrlich said. And because so many of her patients are diabetic, she has a paperless hotlink she emails with background on the disease and treatment options, "which helps support the conversation I have with my patients."

Navigating the materials and websites may require some extra time initially, she says. But participation in the program is voluntary and does not come with any maintenance-of-certification-type requirements.

Nor does Dr. Ehrlich find it prescriptive. "If I don't agree with a particular bullet point on bone density testing only for patients over the age of 65 when there aren't any other risk factors, I can drill down into the literature to find out where that comes from."

And AHRQ's multilayered vetting process of the available research involves more rigor than most doctors have time for, Dr. Villamaria adds. 

"So we can be pretty confident that what the final report says is a good summary of our knowledge at that point in time. And it's really helpful to have the bottom line on what works for doctors who are busy seeing so many patients a day and really don't have the hours to go and do these analyses on their own," he said. 

The only concern the council members expressed was over the hurdle ARHQ faces, just like doctors do, in keeping pace with the latest scientific evidence, given health care's rapid advances. With diabetes in particular, new classes of drugs continue to hit the market, Dr. Ehrlich notes. 

Recognizing that challenge, Dr. Janakiraman says AHRQ reviews its reports annually to learn whether publication of additional studies changes the existing evidence base. 

For example, physicians and patients might see a banner on the website explaining that the conclusions in an older report either remain valid or are under review and should be considered with caution. The brochures also tell physicians and patients how many studies AHRQ reviewed and the time frame of those studies. 

For the most part, Dr. Villamaria says physicians can't go wrong by incorporating the resources into their quality improvement tool belts. "Treating patients in the most evidence-based manner is always going to be the best choice."   

Amy Lynn Sorrel can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.

SIDEBAR

Delivering Effective Care

The Agency for Healthcare Research and Quality's (AHRQ's) Effective Health Care Program provides free tools that help physicians practice evidence-based medicine. AHRQ summarizes the findings of scientific research on the effectiveness, benefits, and risks of treatment options for the sample of chronic health conditions mentioned below, among others, and translates the findings into practical resources. 

  • Brain and nerve conditions;
  • Cancer;
  • Diabetes mellitus;
  • Gynecology; 
  • Infectious diseases and HIV/AIDS;
  • Mental health;
  • Muscle, bone, and joint conditions;
  • Obesity; and
  • Pregnancy and childbirth. 

Diabetes and cardiovascular disease research summaries and other tools are downloadable at no cost on TMA's website. Information on other conditions and additional free resources are available online.

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