It’s a case of “I think” versus “The research shows that…”
So while Mrs. Jones in 3B probably wants her orthopedist’s expert opinion, she will likely benefit from hard data even more. Such is the message being heralded by the thought leaders at the American Academy of Orthopaedic Surgeons (AAOS). Dr. Michael Keith, Chair of the AAOS Evidence Based Practice Committee, explains, “From a philosophical standpoint, the goal is to convince our colleagues in orthopedics that evidence based medicine (EBM) is a better basis for practicing medicine than opinion, consensus or outside mandates such as cost containment. We aim to increase recognition of quality as the driving force behind change in healthcare policy, as well as to create solid standards. On the practical side, we are working to ensure that evidence based medicine penetrates education and training, clinical practice and other activities such as board certification, certificates, and leadership training.”
While it may seem that opinion is being put under the microscope, orthopedists, having studied the hard sciences for many years, have a natural bent for evidence. Dr. Keith:
Orthopedists are naturally inclined toward science, so EBM should be a good fit. Those who are already accepting of this approach are interested because they want to be able to defend what they do as best practice and they want to be judged based on the correct standards. And to those holding out, I say, ‘Opinion loses against a controlled, prospective, randomized study every time.’
It is often the case that younger people are more open to change. With an eye toward influencing orthopedists in training, AAOS has instituted a program to change orthopedic education so as to emphasize evidence based medicine. “We are beginning a program with the Residency Review Committee to include EBM as a foundation for education, meaning that it will be present throughout the curriculum for residents and fellows. For example, this will mean that journal clubs include an assessment of the level of evidence of all published reviews and that these reviews will be compared against the appropriate guidelines. The outcome, of course, is either that the old belief is supported or the new information rejects the formerly held belief.”
Souce: commons.wikipedia.orgIn such a clear-thinking environment, there is no room for bias. Dr. Keith: “We are also working with the Orthopaedic In-Training Exam Committee to include questions about EBM and to upgrade the way questions are written. It is important that the questions are not derived from the question writer’s experience or his or her selected publications, but reflect what one would find in a systematic review of the literature. On our end, the Evidence Based Practice Committee takes several steps to eliminate bias, including that when we write clinical practice guidelines and reviews we don’t even look at the abstract or the conclusions, we just look at the data.”
Hearing From Doctors and Patients
Also part of this continuous quality improvement process is an effort to develop self assessments for surgeons. “We are collaborating with the American Board of Orthopaedic Surgeons and the Council on Education to develop a practice improvement module that includes miniature versions of self assessments in which surgeons can study their practice relevant to one of the guidelines. This will enable surgeons to determine how well they performed, introduce changes and then follow up later to see if the quality of the results improved. At present there are two such modules under study, one on blood utilization and another on MRI utilization.”
In an effort to get everyone on the same page, the AAOS Evidence Based Practice Committee is also reaching out to the leaders of the specialty societies. Dr. Keith notes, “We hope to partner with the specialty societies, and in fact are planning for a specialty society symposium on EBM. The fact is that the leadership of these organizations may not all be trained in EBM. But if we want only the best people heading up the societies, then we must bring everyone up to the same level of education on EBM.”
When given the podium, Dr. Keith first of all stumps for the patients. “Our colleagues should understand that we use EBM to help express the patient’s perspective. Even though most traditional publications don’t speak from the patient’s point of view, it is our objective to ensure that the patient’s side is given a full hearing.”
And a full hearing from patients, says Dr. Keith, means thousands of data points. “Part of outcomes research is that we now expect to have a patient’s rating of how well the surgery worked. For example, take pain relief. In surveys done about patient priorities, they are asked how much change in pain is worth the operation. We want to look at thousands of patients and see what their collective patient experience is. That way, we will have data that says, for example, ‘Well, if the surgery doesn’t eliminate half of my pain then it is not worth the anesthesia, physical therapy, etc.’”
Dr. Keith’s final point: “It is hard to imagine an orthopedic surgeon who doesn’t believe in science…and if you believe in science, you can believe in the value of evidence-based medicine.”
Growing Pains: The Beginnings of EBM
Dr. William Watters, III, Chair of the AAOS Guideline and Technology Oversight Committee (GTOC), concurs, and gives a bit of history. “Great Britain and Canada began having a problem with healthcare resources long before we did; they began emphasizing evidence based medicine in the 1980s. It wasn’t until the late ‘90s that American physicians and researchers began examining EBM. Since that time AAOS has restructured itself and has committed to promoting the concept of EBM.”
Source: commons.wikipedia.orgBut first they had to understand it. Dr. Watters: “When the GTOC was initiated in 2006 those of us involved had to educate ourselves on evidence based medicine by reading copious amounts of literature. We began to look at how to develop guidelines, and then the AAOS Board committed to fund the development of two initial guidelines, one of which was on pulmonary embolism in joint replacement patients. This was chosen because it was highly pertinent to the membership at large and was also an issue about which we were getting conflicting information. The other guideline was on the diagnosis of carpal tunnel syndrome, an important subject that affects several types of specialists.”
They expected—and encountered—growing pains. “‘Where do we get our evidence? How do we analyze the data?’ were some of the questions that gave us pause at the outset. We retained an outside vendor, a university based group that had done this type of work for quite some time. Then AAOS decided to create its own such group, and chose veteran researcher Charlie Turkelson, Ph.D., to lead a new analysis group at AAOS. (This has been such a success that we have never again needed an outside vendor.) There were things to be worked out, of course, but the primary takeaway from this era was that the leadership of AAOS was extremely committed to advancing evidence based medicine.”
Part of the strategy to be worked out was which, among the numerous possible topics, should be addressed. “Dr. Turkelson developed an invaluable topic prioritization matrix that we use as a guide to decide which health issues to study. It includes questions such as, ‘Does the health problem carry a high individual or population burden of morbidity, mortality or disability? Is it something important to the membership at large and beyond? Does the problem, its treatment or diagnosis carry a high unit or aggregate cost?’”
“Based on that matrix, ” says Dr. Watters, “we can generate a hierarchy of topics. The committee typically develops three or four guidelines per year, with each topic having its own workgroup comprised of approximately six to eight people. While those in the workgroup should of course have experience with the topic, as well as be versed in EBM, they are not only orthopedists, but physical therapists, rheumatologists, etc.”
And all on board must be above board. “A major part of the process is full disclosure, ” states Dr. Watters. We must eliminate even perceived conflicts of interest. If we are putting out a guideline for treatment we don’t want someone to say, ‘Dr. X is on that committee and he was the co-developer of such and such product.’”
Once the decks are cleared of conflicts, the workgroup comes together in Chicago for a day long meeting. “During this time the questions to be addressed are chosen and the members of the evidence analysis group perform a literature search and rate the evidence. They and the workgroup then reconvene for two days to answer the questions with the best evidence available and to hammer out the initial draft.”
Which Issue Will Evidence Tackle Next?
And what is the Guideline and Technology Oversight Committee crafting at present? Dr. Watters: “Our workgroups are now developing guidelines for Achilles tendon rupture, ankle arthritis, distal radial fractures, and periprosthetic joint infections. In the past we have addressed, among other things, carpal tunnel syndrome, knee arthritis, and pediatric femoral fractures.”
A torrent of possible topics, along with the need to stay current, means that the committee is always on duty. Dr. Watters explains, “The data for each guideline is reviewed every three or four years, with a new literature search to fill in any gaps. There may be nothing of substance to add, or, there may be so much new information that we need to rewrite the guideline.”
While nowadays those involved in evidence based medicine are not usually met with suspicion, it wasn’t long ago that they had to fight an uphill battle. “The initial reaction to EBM amongst our colleagues was less than enthusiastic. To many, an evidence based approach was viewed as cookbook medicine that discounted the role of the doctor and his or her training. In fact, EBM values the training and experience of the physician, while taking into account the patient’s expectations and desires and presenting the most recent evidence available.”
It is impossible for any doctor to read all of the available literature in his area of specialty. These guidelines take the ‘cream’ of the information and give the doctor and patients the best information with which to make joint decisions. They are not in any way meant to distance the patient from the physician or the physician from the decision making process. The guidelines are empowering for both the patient and doctor.
Commenting on another significant benefit of evidence based medicine, Dr. Watters concludes, “If you work from the goal of always behaving ethically, then the whole process of evidence based medicine is self correcting. If you are following the evidence then you are going to make an ethical decision. And we did take an oath to be ethical.”
