An Evidence-based Practice Center in an Academic Medical Center Supports Continuing Quality Improvement

Joel S. Betesh, MD; Matthew D. Mitchell, PhD; Craig A. Umscheid, MD, MSCE

University of Pennsylvania Health System www.uphs.upenn.edu/cep

The University of Pennsylvania Health System (UPHS) is a major

US academic medical center. UPHS consists of three teaching

hospitals, two primary care and specialty networks, a rehabilitative

nursing facility, a hospice, and

a home health agency.

With so many institutions and

so many providers, the poten-

tial for variations in practice

is high. Such variations can

adversely affect the quality,

safety, and value of care.

Establishment of CEP

The Center for Evidence-based

Practice (CEP) opened in July

2006. Its mission is to gather

scientific evidence and apply it

to decisions regarding clinical

practice, formularies, and

purchases, and, in the process,

reduce unnecessary variations

in care and maximize the value

of each dollar invested in

patient care. The center’s primary financial support comes from

the office of the Chief Medical Officer (CMO).

Staffing and resources

Two co-directors

Physicians (internal medicine faculty with hospitalist specialization)

Trained in clinical epidemiology

Regular patient care responsibilities in our hospitals

Three full-time research analysts

Doctoral-level training

Diverse backgrounds including health policy, nursing, and research

Four physician and nurse liaisons

Clinical leadership at the hospitals and outpatient practices in our system

Bring topics of interest in their institutions to CEP’s attention

Help disseminate report findings back to their institutions

Two clinical liaison librarians

Assist with searching for and acquiring evidence

Teach evidence-based practice methods to library users

Consulting partners

Biostatistician

Health economist with pharmacoeconomics background

Administrative assistant

Total staffing: 5.5 FTE

Annual budget: $750,000

Clients served

Academic years 2006 – 2009

More than half of

the reports were

commissioned by

hospital and health

system CMOs or

purchasing

committees.

Most clients were

from the UPHS

flagship hospital.

Academic years 2009 – 2012

Clients are from all health system hospitals and many outpatient practices.

Clinical departments now represent the most frequent user of CEP reports.

New opportunities emerging with the introduction of computerized clinical

decision support systems across the health system.

Source of request AY 2007-2009 AY 2010-2012

Clinical Department 9 (12%) 31 (30%)

CMO 18 (23%) 19 (18%)

Purchasing Committee 23 (29%) 8 (8%)

Quality/Safety Committee 11 (14%) 15 (15%)

Pharmacy Committee 5 (6%) 13 (13%)

Administrative Department 2 (3%) 7 (7%)

Nursing Administration 4 (5%) 2 (2%)

Other 6 (8%) 8 (8%)

Total number of reports 78 (100%) 103 (100%)

Center for

Evidence-based

Practice

Physicians and Nurses Pharmacy and Therapeutics Committees

Supply Chain and Technology Committees

Clinical Effectiveness and Quality Improvement Provides local utilization and outcomes data

Uses CEP evidence to develop quality programs

Clinical partners Request review of drugs, devices, procedures, and processes of care

Provide clinical context for evidence reviews

UPHS Executive Staff (Chief Medical Officer) Sets priorities for clinical guideline development

Uses CEP evidence to develop quality improvement partnerships

CEP information products

Evidence Reviews:

Systematic reviews of published clinical studies on a well-defined topic, with

meta-analyses of data when appropriate. These are similar to evidence reports

published by other comparative effectiveness organizations. Local utilization and

cost data are incorporated so reports are tailored to our medical center’s needs.

Evidence Advisories:

Concise reports typically based on limited searches of guidelines and systematic

reviews. An advisory can often answer a question more efficiently than a full

evidence review.

Evidence Inventories:

Summaries of the quantity and type of published evidence for a particular topic.

Inventories offer a snapshot of the research landscape and can help determine

the need for a full review.

Clinical Practice Guidelines:

Developed in collaboration with a task force of key stakeholders and includes

practice recommendations. An Evidence Review is part of the process.

Sample topics R–Evidence Review

A–Evidence Advisory

I–Evidence Inventory

G-Guideline

Process of care

•Guidelines for admission

to long-term acute care

hospitals (A)

•One to one nursing care for patient safety (R)

•Telemedicine in follow-up of chemotherapy patients (R)

•Best practices for preventing aspiration pneumonia (A)

•Management of acute lower GI bleeding (G)

•Symptom-triggered vs. fixed-schedule treatment in alcohol withdrawal

syndrome (R)

Device

•Antimicrobial sutures for preventing surgical site infections (R)

•Portable intermittent compression devices to prevent VTE (A)

•Indications for robotic-assisted surgery (I)

Drug

•Hyperthermic intraperitoneal chemotherapy (A)

•Gastrointestinal bleeding risks with celecoxib (R)

•Safety and effectiveness of rhBMP-2 for spinal fusion (R)

Diagnostic Test

•Brief screening tests for depression in ED patients (R)

•Use of ultrasound for diagnosis of DVT in asymptomatic patients (G)

Other

•Physician compensation and medical professionalism (R)

•Defining preventable readmission (Special Report)

Type of topic AY 2007-2009 AY 2010-2013

Drug 19 (24%) 25 (24%)

Device 26 (33%) 20 (19%)

Diagnostic 3 (4%) 8 (8%)

Process of Care 27 (35%) 46 (45%)

Other 3 (4%) 4 (4%)

TOTAL 78 (100%) 103 (100%)

Using evidence to transform care

Example: Transfusion thresholds

Evidence Advisory protocol

Review of published guidelines

Indications for transfusion in adults

Evidence Advisory findings

Table of recommended indications for transfusion, stratified

by three hemoglobin levels

Implementation of evidence-based practice

Clinical decision support tool presented those indications in the

inpatient EMR screen for ordering RBCs

Physician must check one of those indications or explain

clinical rationale for transfusion

Clinical results

15% fewer patients given RBCs

21% reduction in total RBC orders

Example: Systems for early detection of sepsis

Two CEP evidence reports

New technologies for prediction or early detection of sepsis

Clinical risk scores for prediction or early detection of sepsis

Evidence Advisory findings

Low quality, indirect evidence for aPTT waveform analysis

No evidence on the predictive ability of biomarker tests

Low-quality evidence for clinical risk scores to predict sepsis

Moderate evidence for clinical risk scores to detect sepsis

No evidence for commercial risk scoring products

Implementation of evidence-based practice

Clinical prediction rules used to develop automated alert in

inpatient EMR

Care team including physician text paged and told to gather

at the bedside within 30 minutes to evaluate patient

Clinical results

Automated alert implemented September 2012

Survey of caregivers following the first two weeks of operation

6 of 63 patients with sepsis or other critical illness (10%)

were detected first by the automated alert

33 of 103 patients (32%) were transferred to the ICU

41 of 103 survey respondents (40%) thought the alarm had value.

Introducing CEP Dissemination of findings

All CEP reports are posted to a searchable internal web site avail-

able to all health system faculty and staff. Most reports can be

made available to outside users on request. We disseminate our

findings most often through the CRD Health Technology Assess-

ment database, which is searchable through the Cochrane Library.

CEP has developed two guidelines published by the Centers for

Disease Control and Prevention, and three more are in progress.

Other guidelines are submitted to AHRQ’s National Guideline

Clearinghouse.

Beginning in October 2012, CEP will be participating in the AHRQ

Evidence-based Practice program, in partnership with the ECRI

Institute. The AHRQ-designated Evidence-based Practice Centers

perform systematic reviews to inform major health policy decisions

and translate research findings into practice.

Education Initiatives

Faculty and staff education

•“Academic detailing” thru distribution of InfoPOEM and

PROVE (Penn Reviews of Value and Effectiveness) e-mails

•CME credit for CEP task force participants

•Local and national conferences and workshops

Fellow education

•Direct and teach systematic review and meta-analysis course

Resident education

•CEP elective on evidence-based medicine

•Participate in Clinical Investigator Toolbox and Healthcare

Systems Leadership & Quality Improvement Track programs

Medical student education

•Direct and teach in clinical decision making courses

•Small group instructors in epidemiology & health policy courses

Scientific contributions

•41 articles published in peer-reviewed journals

•31 presentations at international scientific conferences

•Participation in methods development groups like GRADE

UPHS internal web site 181 (100%)

Integrated into clinical decision support 35 (19%)

Peer-reviewed publications 19 (10%)

National Guideline Clearinghouse 5 (3%)

Health Technology Assessment database (Searchable through Cochrane Library)

136 (75%)

Other means of dissemination 9 (5%)

AHRQ EPC program Beginning 2012