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Evidence-based Medicine

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Projects focus on ways to integrate research and evidence into clinical practice

Studies show that only 60 percent of patients with chronic conditions like asthma and diabetes receive recommended care. Yet research has shown that there are effective strategies to manage most of these conditions, and they could help improve patient outcomes if implemented successfully. To accomplish this, it is necessary to translate the findings of well-designed research studies into everyday clinical practice.

Toward that end, the Agency for Healthcare Research and Quality funded 27 Translating Research into Practice (TRIP) grants in 1999 and 2000, which targeted a variety of health care providers, settings, and patients. These projects are summarized in a recent article authored by agency staff. In a second article on integrating research findings into practice, staff from AHRQ and the Centers for Disease Control and Prevention review the evidence on population- and health systems-based interventions for smoking cessation. Both articles are discussed here.

Farquhar, C.M., Stryer, D., and Slutsky, J. (2002). "Translating research into practice: The future ahead." International Journal for Quality in Health Care 14(3), pp. 233-249.

This review of the 27 3-year TRIP projects funded by AHRQ in 1999 and 2000 points out that the overall goal of these projects was to evaluate clinical interventions, based on findings derived from sound research, for their effectiveness at changing processes and/or outcomes of care and to demonstrate whether they are sustainable, reproducible, and generalizable. A second goal was to demonstrate that the translation of research into practice leads to measurable and sustainable improvements in health care. The TRIP projects, mostly randomized controlled trials, focused on a wide variety of health care providers, patients, and settings. The framework for change was most often organizational theory or adult learning.

Typical TRIP interventions examined in these projects included: communication/behavioral interventions to improve diabetes care for indigent patients at community health centers; just-in-time reminders for nurses doing home visits; patient education for patients with heart failure and cancer; computer-based clinical decision support systems to reduce adverse drug events among long-term care residents; decision support and coaching for patients after heart attack; Web-based training for primary care physicians and clinic nurses to test sexually active teens for chlamydia; personalized data feedback and educational office visits for adult cigarette smokers; and use of asthma management programs to improve care for children with asthma.

The most common TRIP interventions were multifaceted educational strategies, with academic detailing, opinion leaders, and feedback on practices commonly used. More than half of the projects (17) planned to use information technology, and 13 projects focused on reducing medical errors. Most of the projects provided evidence of collaborations between networks of health care providers and hospitals and the researchers. AHRQ anticipates that such relationships will determine whether research translation efforts are truly effective when applied in health care settings.

Reprints (AHRQ Publication No. 02-R083) are available from the AHRQ Publications Clearinghouse.

Husten, C.G., Hopkins, D.P., and Williams, C.G. (2002, June). "Making the most of evidence-based research: Translating research into practice." Preventive Medicine in Managed Care 3(3), pp. 73- 83.

These authors review research evidence related to the design of integrating smoking cessation programs that involve population- and health systems-based interventions, as well as interventions focused on individuals. Efforts directed at the individual clinician have had limited results. For example, some evidence showed that fewer than 30 percent of smokers were advised to stop smoking during a clinical visit. Tobacco dependence is a long-term chronic condition much like diabetes and hypertension, which involves periods of relapse and remission, requires ongoing rather than acute care, and has effective treatment to achieve long-term or permanent abstinence. Therefore, health care systems should be committed to long-term treatment.

Recent guidelines from the U.S. Public Health Service (PHS), the Task Force on Community Preventive Services, Office of the Surgeon General, the Centers for Disease Control and Prevention (CDC), the Cochrane Collaboration, and the U.S. Preventive Services Task Force have examined the effectiveness of various smoking cessation interventions. They recommend patient screening for tobacco use, brief advice to quit from a health care provider, more intense counseling (individual, group, telephone), and pharmacologic treatment (for example, use of nicotine gum, patch, nasal spray, inhaler, or Bupropion SR). Studies suggest that price increases for tobacco, media-based activities, reducing out-of-pocket costs for treatment, and provider reminders alone or in combination with provider education are effective system- and population-based strategies.

The guidelines make it clear that managed care organizations that want to have an impact on tobacco control should focus on system- and population-level interventions, as well as individual tobacco users. They make the following system-level recommendations. First, all health insurance plans should include as a reimbursed benefit the counseling and drug treatments identified as effective. Second, clinicians should be reimbursed for providing treatment for tobacco dependence just as they are reimbursed for treating other chronic conditions. The CDC's National Tobacco Control Program Framework involves four components: community interventions, counter-marketing (anti-smoking campaigns), policy interventions, and surveillance/evaluation.

Reprints (AHRQ Publication No. 02-R082) are available from the AHRQ Publications Clearinghouse.

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