I am a member of an international listserv about evidence-based healthcare. One poster asked “Is EBM patient-centered and is patient-centered care evidence based?” It is almost as if he views the 2 as exclusionary. In my experience many people don’t understand the EBM paradigm. This figure shows what EBM is and that it,by definition, is patient-centered.
The most important component of the EBM paradigm (the circles are in the order of importance) is patient preferences and actions. An evidence-based decision should consider patient values. Period. Thus, EBM is patient-centered.
Question 2: Is patient-centered care evidence based? It can be but might not be. Patients often don’t want the evidence-based care I offer them like immunizations or colon cancer screening. So they aren’t receiving evidence-based care but they are receiving patient-centered care.
A study published in the American Heart Journal shows what putting the cart before the horse does (http://www.ncbi.nlm.nih.gov/pubmed/22795286?dopt=Abstract). What do I mean? We (the collective we) roll out performance measures without testing them. Like any other intervention we should make sure they work to achieve the desired outcomes- improved “performance” (notice I didn’t say quality….but that’s a whole topic in and of itself). But as usual someone thinks up a measure and we adopt it just because it might make sense.
The measures that were tested were:
- evaluation of LV systolic function
- administration of ACE-I or ARBs
- provision of smoking cessation counseling, and
- provision of discharge instructions
The outcomes they hoped to improve were 30 day mortality and hospital readmission- both worthy goals. The study showed that hospitals did a good job meeting these measures (94% with all 4 measures). Despite this…
“After adjusting for factors including patient demographics, socioeconomic factors, hospital volume, and type of hospital, there were no differences detected in 30-day mortality or readmission rates between hospitals in the top 25% and all others
The authors did find that hospitals located in areas with higher household income and those with a greater volume of HF admissions had decreased mortality rates.”
This is the second study on this same topic which essentially showed the same thing (JAMA. 2007;297:61-70)
“Current heart failure performance measures, aside from prescription of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker at discharge, have little relationship to patient mortality and combined mortality/rehospitalization in the first 60 to 90 days after discharge. Additional measures and better methods for identifying and validating heart failure performance measures may be needed to accurately assess and improve care of patients with heart failure”
So why don’t we require measures be tested before we monitor hospitals and physicians for compliance with these measures? Surely we wouldn’t treat a new drug the same way?