Evidence-based Practice Centers Reduce Costs, Improve Care

If an EPC does enough big projects, "one or two or three a year, you more than pay for your entire budget," says the head of Penn Medicine's Center for Evidence-based Practice.

Evidence-based practice centers in hospitals can facilitate and accelerate the use of best practices to improve care and save money, research suggests.

Penn Medicine has had an EPC since 2006. A recent review of the center's first eight years found that nearly 250 analyses were produced mainly at the request of clinical departments, purchasing committees and CMOs, primarily for drug and device performance.

The researchers analyzed an internal database of evidence reviews performed by Penn Medicine's Center for Evidence-based Practice and then conducted an anonymous web survey of all of those who requested a report during the last four of the Center's eight fiscal years.

The survey data of 46 respondents found that 98% of report requestors said the scope of the review and level of detail was "about right," and 77% said reports confirmed their tentative decision. When asked whether the report informed their decision, 79% "agreed" or "strongly agreed." The survey respondents also found the reports easy to request, easy to use, timely, and relevant, resulting in high requestor satisfaction, Penn Medicine reported.

The most common reasons cited for requesting a report was the EPC's skills in identifying and synthesizing the available evidence, and the EPC's objectivity.

Study lead author Craig A. Umscheid, MD, director of Penn Medicine's Center for Evidence-Based Practice, and a practicing internist, says the EPC's credibility underscores the value of a neutral center in an environment where clinical departments and hospital committees may have competing interests, and where politics and external influences such as industry may negatively influence institutional decision making.

Umscheid spoke with HealthLeaders Media about the value of EPCs. The following is an edited transcript.

HLM: Can you call Penn Medicine's EPC a success?

Umscheid: It all depends on how you define success. In our study we were able to show that if you have a center available and it is positioned within a layer of a health system that is responsible for decision making, people will access the center, use the center for a variety of topics, and when they access us we can get the work done so that it can be used in a timely manner. So if you define success in that way, we have demonstrated you can be successful.

HLM: Generally speaking, how long does it take for best practices to be commonly adopted?

Umscheid: Traditionally, this is referred to as the knowing/doing gap; the gap between what we know works and what we actually do on the ground. Oftentimes you will see a number such as 17 years before research that is published is translated into practice. I think that number is incredibly outdated.

It is much more rapid nowadays. That can be a good thing and that can be a bad thing. In terms of whether doctors practice current medicine, it is variable. It could vary by the provider within an institution. Some physicians are more conservative. Some specialties are more conservative.

Other physicians and specialties are more interested in being on the leading edge. That is their culture, whether that is best for their patients or not. And then institutions have their own cultures of being conservative or leading edge cultures. It is difficult to generalize.

HLM: Do you see EPCs accelerating the adoption of best practices?

Umscheid: I absolutely see them as such. I see our work as for the most part implementation work. People come to us with questions that are informed by a variety of events. Whether it is news media, patients, or problems that are identified on the ground. They want to know what are the best practices for achieving 'X' or is 'A' really better than 'B.'

We can help synthesize that for them quickly, or find syntheses that are already available and get that to them to inform the decision-making for their unit or their clinic or their hospital.

So often people say physicians need to read their studies more or guidelines have to be more updated, but the systems that we have in place are exactly the systems that create the outcomes we are seeing. That's a Don Berwick quote. If we want to change the outcomes we have to change the systems. The types of centers we are describing have the potential to provide infrastructure to assist not just individual providers, but institutions and integrating evidence into practice to improve care.

HLM: Could a hospital or health system with fewer resources create an EPC?

Umscheid: Most institutions could do this. It doesn't have to be on as large a scale as we have. Most corporate layers of institutions could probably hire or redeploy someone with a skill set for assessing evidence to do this in a more explicit way for high-priority decisions. In fact, there are probably many institutions that do this, but it is less formal or publicized or evaluated.

HLM: Do you believe these EPC fosters culture of improvement?

Umscheid: That is a change we have seen over time and it's a palpable change; people asking for the evidence in a position to make important decisions. It's really gotten a foothold and we have been able to catch the ear of people who are respected in their hospitals and clinics and it has slowly changed the culture here.

HLM: Are you able to determine a return on investment?

Umscheid: We don't have a systematic assessment of our ROI. What we have done, particularly over the first few years and particularly for large projects that are amenable to this, is estimate impact on outcomes that have direct links to costs.

For example, in the past we did a large review comparing different products to prevent surgical site infection so one of the products was a standard Betadine that you put on your skin versus a new product call Chlorhexidine, which costs more money, but which dramatically reduced surgical site infections when compared with Betadine.

We found about a $400,000 savings for one hospital for the use of that product, and for a number of different projects we have done those types of estimates. And if you do enough of those big projects, one or two or three a year, you more than pay for your entire budget, which is about $1 million a year.

That is particularly true nowadays because in the past few years the policy environment in the U.S. has focused much more on value-based purchasing and pay for performance. If we don't meet these process or outcome metrics, we lose money or reimbursement. If we are able to actually implement a process and outcomes or measures improve all of these things can result in increased reimbursements or savings.

HLM: Should EPC researchers continue to practice medicine or should they remain separate?

Umscheid: It is absolutely critical for someone who is leading a center like this to be practicing clinically, to be seeing patients regularly and working with colleagues in the clinical context regularly. If you don't do that, your credibility is lacking and your perspective when you're helping to inform staff about these reviews isn't as robust and realistic and relevant as it should be."

HLM: How has the role of the EPC evolved since it started?

Umscheid: It's been gradual. When we set up this center back in 2006 we assumed we would be looking at drugs and devices and mostly informing the formulary committee, or the health system purchasing committee about buying 'Device A' versus 'Device B.' As we developed more traction, and gained more colleagues and fellowships, much of the work we do now is about best practices and processes of care, helping different groups identify those best practices for achieving better outcomes be it in an outpatient or inpatient setting, and many of those colleagues are clinician or nurse colleagues. It's become less about drugs and devices and more about processes of care.