According to the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine, in order for health care systems to improve health quality, outcomes, cost, and equity there needs to be a process for transmitting new knowledge into everyday care. Systematic reviews are one potential source of knowledge. However, little is known about the types of evidence used by health-systems and how evidence reports produced by the Agency for Healthcare Research and Quality (AHRQ) Evidence-based Practice Center (EPC) program could be used by learning health-systems.
To better understand how health-systems identify and use evidence and how EPC reports could help them with their decisionmaking in the future.
From February to September 2017, an AHRQ/EPC Methods Workgroup interviewed nine individuals with leadership roles in enhancing health-system quality, safety, and process improvement from academic, non-academic, and small community health-systems, as well as health-system collaborative organizations. Workgroup members reviewed interview notes and transcripts to identify key themes and exemplar quotations. The nine Key Informants (KI) reviewed the draft report for accuracy.
Health-systems have various internal processes for getting and using evidence in their decisionmaking. All of the health-systems we spoke with have either centralized and standardized quality, safety, and process improvement functions within their health-system or have formed partnerships with other organizations to support these improvements. Health-systems recognize that evidence and improvement ideas can come from both the top down (from leadership to local level) as well as from the bottom up (local to leadership). One common process was to conduct searches themselves to obtain information and evidence from the literature. However, there was variation in how this information is obtained. Some of the larger health-systems have medical librarians and centralized committees to gather and disseminate this information. For smaller systems, it is more common that the local chief medical officers or clinical champions identify the information. Other processes for getting evidence include: using internal data to benchmark performance across the system and identify where improvements are needed; and forming subspecialty committees within the health-system to review information and make improvement recommendations within the subspecialty (e.g., cardiology, oncology, and orthopedics). Some of the challenges to the existing processes include: how to resolve conflicting information and whether the information applies to local needs; and how to know whether information is up-to-date. Health-systems feel the standard timeframe to generate systematic reviews is very long, which could hamper optimal utilization in decisionmaking.KIs generally feel that guidelines and systematic reviews are excellent sources of evidence and facilitate quality, safety, and process improvements. While some clinical experts in the health-systems prefer randomized clinical trials, most people in health-systems prefer the synthesized data in guidelines and systematic reviews. KIs generally prefer guidelines, especially those with treatment algorithms, because they are more actionable. KIs prefer evidence from systematic reviews to be summarized into short digestible summaries with the option to click on a link for the more detailed report. They also prefer systematic reviews from known entities and entities that do not have commercial bias. KIs suggest alerting people at multiple levels in a health-system when new evidence reports are available via email or listserv. Some KIs, especially those in small and rural health-systems, noted that they want to be able to obtain evidence in standard search engines, such as Google, rather than having to rely on literature databases. Some KIs felt that they could partner more closely with AHRQ to identify topics but felt that the prolonged turn-around time from topic generation until the report was available could be a barrier. The topics of greatest interest to health-systems varied, but some of the most common ones include: predictive analytics; high-value care; advance care planning, and care coordination.
Recommendations and Conclusions
Based on these interviews, we recommend the consideration of the following key actions to make EPC reports more useful to health-systems:
- Modify the dissemination emails that go out to health-systems to include not only the titles of the reports and hyperlinks to the full reports, but to include key messages (or hyperlinks to key messages) so that potential users can better assess the relevance of their report to their decisionmaking and better triage the findings internally within their system.
- Periodically construct an EPC newsletter—perhaps building off the existing EHC listserv—with a format similar to "The Medical Letter" or "Prescriber's Letter," which provides short three of four sentence summaries of report highlights with hyperlinks to reports.
- Ensure that EPC reports are searchable both within PubMed but also within common search engines such as Google, Bing, and Yahoo. This would include having medical librarians test search using these sites, strategize how to enhance the chances of finding reports for educational purposes, and to reach out to the common search engines and inquire about ways reports can be designed to enhance pick up in searches.
- Explore opportunities to deliver reports more quickly, perhaps through further limiting the scope of a project, writing more focused reports, or by dividing a larger topic into two or three subtopics so that more timely evidence can be available to health-system decision makers.
- EPC reports should not make clinical recommendations like guidelines. However, if the reports could more clearly identify what the current process of care is for a target disease or disorder and where the trials/studies being summarized or pooled will inform decisions that members of health-systems could make, it would make the results more actionable.
- Conduct broad outreach to health-systems to alert them of the topic nomination process so that these topics can be considered within the EPC program and discuss partnerships not unlike those AHRQ has with guideline groups and other Federal agencies. AHRQ and the EPCs can begin with the contacts made with health-systems from this project, contacts identified from the Spring 2017 EPC meeting, and contacts identified from the health-systems which have EPCs to form an advisory group and devise a strategy.
- Establish consistent and prominent branding of the EPC program and its products, ensure that the high-quality journal articles based on our reports are identified as part of the EPC program, and promote the EPC program as a source for timely and reliable reports to improve the quality, safety, and value of care.
White CM, Schmidler GDS. Understanding how health systems view the pros and cons of different evidence types. Doctor Evidence. 2018 Nov 19.
White CM, Sanders Schmidler GD, Borsky A, Butler M, Wang Z, Robinson K, Mitchell MD, Berkman N, Henderson J, Fiordalisi C, Hartling L, Newberry SJ, Guise J-M, Niebuhr D, Pham D, Gozu A, Iyer S, Banez L. Understanding Health-Systems' Use of and Need for Evidence To Inform Decisionmaking. Research White Paper. (Prepared by the University of Connecticut and Duke Evidence-based Practice Centers under Contract No. 290-2015-00012-I and 290-2015-00004-I.) AHRQ Publication No. 17(18)-EHC035-EF. Rockville, MD: Agency for Healthcare Research and Quality; October 2017. https://doi.org/10.23970/AHRQEPCWHITEPAPER2.