Barriers to Using Evidence-Based Medicine
Melanie Ossman
Granite State College
Professor Philip Wyzik
HLTC 600
March 4, 2011

Thesis
The Institute of Medicine recommends the use of evidence-based medicine as a primary tool for achieving the aims outlined by their six themes of improvement. Specifically, EBM relates to their aim to make health care more effective: “to provide health care that is effective and efficient.” (Institute of Medicine, 2001) In recent years, evidence-based medicine has gained increasingly broad-based support in health care, but many doctors still aren’t using it. With a lean towards Pharmacy management, I researched the barriers providers and institutions are faced with in successfully incorporating evidence-based medicine and how initiating organizational improvements can help. The research highlights some important considerations to be aware of that gives evidence-based medicine a bad name, the pitfalls to avoid, and some ways providers and institutions are working to overcome them.

Introduction
This paper begins by giving an overview of evidence-based medicine, what it is, and the benefits to be realized by providers, insurers, and patients. I compared that to what providers were using before EBM. Next, I examine the barriers to successfully incorporating evidence-based medicine, and the negative perceptions that dissuade their use by clinicians. Identified are the disadvantages such as source information bias, ethics considerations, and the dangers in using EBM to set Clinical Practice Guidelines (CPG).
The research highlights some important considerations to be aware of that gives evidence-based medicine a bad name. I looked at pitfalls to avoid and some ways providers and institutions are working to overcome them. Finally, I included an overview, from a pharmacy management perspective, of how improvements techniques can be applied to unobtrusively assist providers and still embody the best intent of EBM.

Background
“Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” (Centre for Evidence-Based Medicine [CEBM], 2009). William A. Miller, in his interview published in Current Concepts in Pharmacy Management, said: “As I see it, in EBM a physician or other health care provider uses the best scientific evidence combined with his or her personal expertise along with the patient’s preferences concerning treatment decisions to make the best decision.”(2010).
First described in 1991, the application of EBM is based on following the five steps of evidence-based practice. (CEBM, 2009). 1. Asking focused questions. In order to find evidence relative to the treatment a physician is researching, the question must be formulated with specific details. Some of those specifics are; the patient and the course of treatment being considered, the comparison to alternatives, and the clinical outcomes of interest. (CEBM, 2009). 2. Finding the evidence. Systematic retrieval of the best evidence available. (CEBM, 2009). Learning to search for relevant literature is a skill. Constructing and conducting an efficient search is an ability that can (and should) be taught to medical students. 3. Critical appraisal of the evidence found. (CEBM, 2009) Practitioners must learn to understand and test the validity and relevance of the evidence. 4. Making a Decision. (CEBM, 2009) Applying the evidence to create a treatment plan. 5. Evaluating Performance: auditing evidence-based decisions. (CEBM, 2009). Auditing is the follow-up to using EBM. It involves collecting data on outcomes of evidence-based treatments and comparing that data with alternative treatments or previously accepted guidelines.
An important factor to using evidence-based medicine is to understand and quantify the quality of the evidence found. “Use of the word “evidence” implies that all evidence is good evidence.” (Miller, 2010) However, not all evidence is created equal. The hierarchal characteristics of evidence are often depicted graphically by a pyramid. (Figure 1.) In his interview William Miller described the levels of evidence. He said:
There’s a ranking of what is considered the best evidence to support medical decision making and what is considered the poorest evidence. What we would call the “gold standard” are randomized clinical trials and systematic reviews in which we review all of the trials, and we look across those trials to make decisions that are evidence-based. Next there are cohort studies and case reports and finally, there are panels of experts that offer their opinion on the best way to diagnose or treat a patient, based upon what they’ve read their interpretation of the literature and their experiences. In summary, the best EBM occurs when the evidence comes from rigorous scientific research through randomized clinical controlled trials. (2010). Figure 1. Pyramid ranking of evidence. (Evidence-Based Practice in the Health Services, 2009). The “gold-standard”, which Miller refers to, is source information from a randomized clinical trial. David Sackett defines it as: “A randomized clinical trial (RCT) is when a group of patients is randomized into an experimental group and a control group. These groups are followed up on for the variables/outcomes of interest.” (Sacket, 2000).
The benefit of using evidence-based medicine depends on your point of view. Patients, providers, insurers, and even the government have different expectations for its application. Miller explains the benefit from a patient perspective, he said: “patients want the best treatment for their condition or disease. They may not be able to articulate that this means they want the physician or pharmacist to use the best evidence to help treat or manage the condition...” (2010). Miller adds: “Patients are very concerned about the costs of medications; with the aging of our population, seniors are especially concerned about the costs. They expect organizations to look at various medications to determine if one is more economical than another with similar outcomes.” (2010). The same is true for providers; they simply want the best outcomes for their patients. Miller said: “I believe physicians, pharmacists and nurses always want to do what is best for their patients. They want to use the best evidence to make the decision to help their patients get better.”(2010). “There have been large studies that have shown that using EBM approaches in making treatment decisions leads to reduced morbidity and mortality in patients.” (Miller, 2010).
Insurance providers and even the government promote the use of evidence-based medicine. The insurance providers, of course, want to save money. “If we look at payers, they are concentrating on studies that indicate the most economically feasible alternative on how to treat a patient.” (Miller, 2010). The government is also interested in keeping healthcare costs down. In an article published in the American Legislative Exchange Council, Twila Brase notes: “…the United States Congress and some state legislatures have begun adding evidence-based requirements to health care laws.” (2008). “The current administration is beginning to promote the concept of prevention versus just treatment. But prevention is very expensive and we have confined or restrained resources.” (Miller, 2010).
Before EBM Now, to be clear, even though the concept of evidence-based practice is relatively new that is not to say that prior to its advent physicians were not using the best treatments available to them. “It is my view that physicians, pharmacists and other providers have been using evidence to make decisions for a long time, even before the concept was popularized.”(Miller, 2010). The difference, it seems, is in the relative age of the evidence. “EBM is better because it is based upon the current evidence concerning what is best today to treat a patient.” (Miller, 2010). Prior to adopting EBM, physicians used the knowledge they gained when they were educated combined with the experiences they’ve learned while in practice. Miller adds: “It may not be as evidence-based today as it might have been 10-15 years ago, when they were training. I think the challenge is for physicians, pharmacists and providers to constantly be looking at the latest evidence and use it in making medical decisions.” (2010). Another resource commonly used by providers prior to EBM is the advice of their colleagues. In the article Evidence-based Medicine and the Practicing Clinician, McAlister, Graham, Karr, and Laupacis noted: “physicians reported relying on their personal experience and the opinion of colleagues most often in their decision making.”(1999). McAlister, et al., (1999), pointed out that “experts and colleagues are a quick, cheap, and easy to use source of information and also provide guidance, support, affirmation, and other psychological benefits that computerized sources cannot provide.” The relative ease and psychological benefits of consulting with colleagues is not the only reason health care providers are averse to using EBM, the barriers can be daunting.

Barriers to using Evidence-based Medicine Evidence-based medicine seems to provide the outcomes that patients, providers, insurance companies, and the government are looking for yet reports still note that “it remains difficult to get physicians to actually practice it.”(Bates, et al., 2003). The barriers to using EBM effectively in clinical practice are numerous.
Negative perceptions exist among providers that preclude them from fully embracing evidence-based medicine. The first barrier is ease of access to information relevant to the condition a provider is treating and the time-constraints that they are under in their practice. (Miller, 2010). Physicians, especially those not trained to search for evidence-based answers, can be easily overwhelmed with studies irrelevant to their query. Grandage, Slawson & Shaughnesssy, (2002) said: “The volume of available information makes clinicians’ tasks of rapidly identifying high-class studies daunting.” Wyer, et al., (2004) noted: “Despite the availability of authoritative texts, teaching clinicians the basics EBM skills of formulating questions, finding the relevant literature efficiently, appraising that literature and applying it to their patient care remains challenging”.
Cost is another barrier associated with evidence-based medicine. Proponents for evidence-based medicine, such as insurance companies, claim there is savings to be realized. Doctors, however, think it only takes them away from time with their patients and, therefore, impacts their bottom-line. In the study Barriers to Evidence-Based Practice to Primary Care by McKenna, Ashton & Keeney in 2002, 35% of general practitioners agreed with the statement: “There are no incentives to develop my research skills for use in my clinical practice.”
The cost to fund high-quality studies is another problem. Twila Brase noted that “a randomized clinical trial typically cost $50 million to $100 million.” (2008). That means that few “gold-standard” randomized clinical trials exist for much of what is practiced in clinics and hospitals every day. (Brase, 2008). It also means that a bias could exist in the studies that are published by those with a large stake it it’s adoption such as a company with a new pharmaceutical agent. (Brase, 2008).
Researchers caution against relying solely on research evidence. The prohibitive cost associated with publishing a randomized clinical trial can simply preclude its creation. “It may only be a short step from the notion that a therapy is “without substantial evidence” to it being thought to be “without substantial value.” (Brase, 2008). Brase goes on to say: The large quantities of trial data required to meet the standards of evidence based medicine are available for relatively few interventions. Evidence based medicine may therefore introduce a systemic bias, resulting in allocation of resources to those treatments for which there is rigorous evidence of effectiveness, or toward those for which there are funds available to show effectiveness. (2008). Many government agencies, insurers, and pharmaceutical companies have latched on to the buzz-phrase evidence-based medicine and are using it to promote and pursue their own agendas. For example, insurance companies interested in controlling the rising cost of health care, spend a great deal of time and money lobbying congress. They are pressing their agenda by convincing politicians to pass health care laws that standardize patient care into one-size-fits-all clinical practice guidelines (CPG’s). (Brase, 2008).
Clinical practice guidelines were developed by managed care organizations in the 1990’s “to identify medical care they deemed inappropriate or unnecessary.” (Brase, 2008). Brase claims that guidelines are being developed “to drive physician adherence to corporate medical decisions.” (2008). The increasing use of CPG’s has led to the argument that it takes the art out of medicine and leads to “cookbook” medicine. “One of the negative perceptions of EBM is equated with “cookbook” medicine, where there is no individual judgment made by providers and patient preferences are not taken into consideration. That was never the intent of the concept of EBM.” (Miller, 2010). Although the American Medical Association is said to endorse guideline flexibility that avoids cookbook medicine, many doctors believe that “guidelines become law, become mandates.” (Brase, 2008).
Increasingly, physicians are being coerced by directives and guidelines that are supposed to be based on evidence but in many cases the evidence is flawed. In Patient Safety: Achieving a New Standard for Care, the IOM notes that authoritative evidence for medical decision making is not clear cut: “There are gaps and inconsistencies in the medical literature supporting one practice versus another, as well as biases based on the perspective of the authors, who may be specialists, general practitioners, payers, marketers, or public health officials.”(2004).
Some research results even contradict each other. In one case, a longstanding Nurses’ Health Study had shown the reduced risk of heart disease from hormone replacement therapy but a 2002 study, by the Women’s Health Initiative, directly contradicted those findings. (Brase, 2008) “The WHI study found that women taking hormones had 40 percent more heart attacks.” (Brase, 2008). Overcoming the Barriers
As physicians, politicians, and policymakers fight for control over medical decision-making, the fact that evidence-based medicine is here to stay is inarguable. To that end, it behooves us to find the best way to make it easy for providers to find the evidence they need in a way that is unobtrusive to their application of medicine. To embrace the original intent of evidence-based medicine physicians first must be taught to formulate their queries, which will narrow their research findings to the most relevant, applicable data. Studies have shown that even a three-hour interactive training session “improved user’s ability to search databases and retrieve evidence.” (Rosenberg, Lusher, Snowball & Sackett, 1998). Teaching evidence retrieval to medical students is also key. McAlister, et al, (1999) noted that: “physicians trained in EBM are more likely to keep up-to-date than their traditionally trained counterparts. Recent physician training reports have called for increased exposure to EBM at the undergraduate and postgraduate levels.” The University of Massachusetts, (2008) teaches evidence based medicine to its undergraduate medical students. The students are introduced to evidence-based retrieval by use of the “5 A’s”: * Asses-Identify the clinical problem. What is it you want to know? * Ask. Use PICO to formulate a good question. * Patient * Intervention-Are you looking to treat? Diagnose? * Comparison- Is there a control/placebo. Is there a gold-standard? * Outcome-What do you hope to accomplish? Better treatment? Decrease mortality?
A good PICO might read: “In an 86 year old man with coronary artery disease, is aspirin a more effective agent than heparin in reducing stroke? * Acquire-Use PICO to search for good evidence. * Appraise. What have you found, where did you find it? Are the results significant to your patient? Is there bias present? * Apply. Apply and discuss the evidence with your patient. At the clinical and organizational level utilizing a medical librarian can play a significant role in teaching evidence based retrieval as well as assisting clinicians with information retrieval, usually through electronic means. (Grandage, et al, 2002). Librarians are increasingly being asked to provide information that is filtered by scientific rigor and relevance to the clinical practice of medicine. New tools evaluate the information and summarize it in the form of synthesized clinical answers. These sources have the opposite focus of many other information tools in that they strive to provide less information rather than more. (Grandage, et al., 2002).
As noted by Grandage, et al., librarians, in addition to their role in archiving information, are now focusing their energy in evaluating the ever-increasing variety of these synthesized resources, placing them into the searching hierarchy, and training clinicians to search from the top down. (2002). “Many librarians are encouraging their users to build their own personalized portals to library home pages for quick access to the resources and services they use the most. Librarians are also looking to handheld computers to provide this information in a clinical setting.” (Grandage, et al., 2002). Employing the use of electronic medical records (EMR) is another way organizations can integrate the tools of evidence-based medicine. Electronic medical records are computerized patient medical records that allow for the storage, retrieval, and modification of information. EMR’s are usually found in a local health information system, such as a hospital. (Miller, 2010). “I believe in the future, an increasing number of hospitals will utilize electronic medical records, which use evidence-based tools that are electronically transmitted during the time that physicians are prescribing to encourage them to use this information in decision making.”(Miller, 2010).

How Applying Improvement Initiatives Can Help By applying a system of improvement an organizations can make the transition to integrating the use of the electronic medical record a more seamless process. The first step suggested by Langley, et al. (2009) is to “begin by letting people know why the change is needed.” (P.46). In this example, the change is needed in order to improve patient outcomes, reduce mortality and morbidity, and comply with the Joint Commission’s National Patient Safety Goals. Implementing the use of clinical pharmacist’s interventions at the time of physician order entry through the use of the electronic medical record will become the initiative we use to achieve our collective goals. Langely, et al., (2009) stress the importance of creating an organizational initiative, stating: “strategic improvement initiatives usually require many parts (divisions, departments and so on) in the organization to cooperate. An initiative gives concrete meaning to cooperative interactions to achieve an aim.” (p. 317). The next step in the improvement process is to “help employees see the organization as a system.” (Langely, et al., 2009. p. 317). By seeing the organization as a system, and even being able to view a linkage of processes, physicians, nurses, and pharmacists will see where and how their work impacts the chain of events in daily patient care. “Individual department managers can also foster a systems view in their employees by relating the department’s work to the overall organization’s initiatives.” (Langely, et al., 2009. p. 317).
Leadership will have an important role in fostering a ‘constancy of purpose’ within the organization, supporting department managers with additional staff and resources. (Langely, et al., 2009. P. 329). In our example, if we want to better support physicians in using evidence-based medicine, we will need to allow for decentralization of our pharmacists to patient floors. In his interview, Miller notes: “A significant factor for pharmacy is the job descriptions of the pharmacists. If we look today at hospitals, increasingly pharmacists are decentralized and function as clinical pharmacists.”(2010). The pharmacists are available on patient floors for questions from physicians and nurses as they are taking care of patients and entering orders.
Bates, et al., noted: “…providers make many errors, and clinical decision support can be useful for finding and preventing such errors.” (2003). By tying into the EMR, pharmacists can use interventions and reminders to find and prevent medication errors in physician orders. Bates, et al. agreed saying: “decision support delivered using information systems, ideally with the electronic medical record as the platform, will finally provide decision makers with tools making it possible to achieve large gains in performance, narrow gaps between knowledge and practice, and improve safety.”(2003).

Conclusion As it turns out, there is a substantial argument against the use of evidence based medicine to the extent that it is used to create mandated clinical practice guidelines to be followed by physicians in setting patient treatment. To be clear, the physicians are not against the use of treatments based on evidence. They are opposed to being told which treatments they must use. The physician and the patient should have the right to pursue the treatment options that work for that individual case, not the ” recipe” for treatment set out by the insurance company.
Overcoming the barriers to using evidence-based medicine should begin with teaching the basics to undergraduate medical students. Practicing clinicians can be supported by having access to medical librarians to help guide their searches and form proper queries. Finally, organizations can institute improvement initiatives and employ the use of technology to unobtrusively guide providers to use the best evidence in caring for patients. It is important to embrace the original intent of evidence-based medicine without mandating the use of restrictive and potentially dangerously biased practice guidelines.

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