Across the Chasm Aim #2: Health Care Must Be Effective

Information for this feature story was obtained from the IHI Calls to Action series, Implementing the Quality Chasm Report.
As medical knowledge advances, so should the care delivered to patients. That’s why effectiveness is one of the six major "Aims for Improvement" in the Institute of Medicine’s 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century. Health care should match science, with neither overuse nor underuse of the best available techniques.
Overuse is the administration of medications, procedures, surgeries, technologies, and visits that cannot possibly help. If the scientific literature would show no justification for the employment of a particular technology for a particular patient, its employment would in fact be overuse. (For an example of overuse of medical techniques, just remember all the expensive advanced antibiotics prescribed unnecessarily for children’s simple ear infections.) Underuse, meanwhile, is "the failure to use a procedure, sometimes a very inexpensive and safe procedure, which could help a patient, but the patient fails to get it," says Donald M. Berwick, MD, MPP, former President and Chief Executive Officer of the Institute for Healthcare Improvement and one of the Chasm report’s architects. Consider failures of immunization in the United States: As of the mid-1990s, half of all elderly Americans were still not receiving the pneumococcal vaccine despite its safety and effectiveness.
A common root cause of the underuse and overuse of medical care is health care providers’ reliance on tradition and anecdotal personal experience. Patients deserve care that is based on the best science, rather than on tradition alone. It has been estimated that about half of all physicians rely on clinical experience rather than evidence to make decisions, even though physicians in most practices do not see enough cases of the same conditions over a long enough time to draw scientifically valid conclusions about their treatment. One important strategy in delivering the best possible care to patients is evidence-based medicine, defined by the Institute of Medicine as "the integration of best research evidence with clinical expertise and patient values." Using evidence often means following clinical guidelines, practicing what was once skeptically called "cookbook medicine." But the fact is, as medicine grows more and more complex, decision support tools become critical elements in providing effective care. Evidence-based medicine includes sophisticated methods of evidence collection, analysis, and integration. No health care provider can hold all of today’s knowledge in his or her head, especially as the body of knowledge continues to change and grow so rapidly.
Decision support can come in many forms. There are sophisticated computer systems that cross-reference symptoms, diagnoses, and medications with patient records, helping care providers keep track of current best practices and patient needs. Or organizations can develop paper guidelines, make them easily available, and update them regularly. It is not the decision support mechanism that matters, but the information delivered to the point of care that enables care providers to make the right decisions at the right time for every patient.
Many organizations are adopting new techniques, equipment, and protocols to bring the best science to patients who would benefit from it. Success stories range from reduced pneumonia rates among Intensive Care Unit patients on ventilators thanks to a well-applied literature review to reduced waiting times for specialty appointments, more effective patient education, and fewer heart failures because of an intelligent redesign of the way care is coordinated and delivered to patients. Richard Smith, MD, editor of the British Medical Journal, says that "to deliver ineffective care well is pointless. To deliver it badly is almost criminal, and yet too much health care around the world is doing exactly that." It is time to think critically about "the way we’ve always done it" and explore smarter, more scientifically valid, and more sensitive ways to care for patients.
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