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Clinical Practice Improvement: Mind the Gap or Fall Into the Chasm

Schwann, Nanette M. MD, FAHA*,†; Engstrom, Ray H. MD; Shernan, Stanton K. MD§; Bollen, Bruce A. MD

doi: 10.1213/ANE.0000000000003877
Editorials: Editorial
Free

From the *Lehigh Valley Health Network, University of South Florida Morsani College of Medicine, Tampa, Florida

Allentown Anesthesia Associates, Phymed Healthcare Group, Allentown, Pennsylvania

Department of Anesthesiology, Valleycare-Stanford Hospital, Pleasanton, California

§Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts

Missoula Anesthesiology and The International Heart Institute of Montana, Missoula, Montana.

Published ahead of print 19 September 2018.

Accepted for publication September 19, 2018.

Funding: None.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Bruce A. Bollen, MD, Missoula Anesthesiology and The International Heart Institute of Montana, 1080 Spurgin Ct, Missoula, MT 59804. Address e-mail to BruceBol@bresnan.net.

The US healthcare delivery system does not provide a consistent, high-quality medical care to all people…Indeed, between healthcarethat we now have and the healthcare we could have lies not just a gap, but a chasm.

—Institute of Medicine (IOM) “Crossing the Quality Chasm” (2001)

Science should be conceived in math but disseminated in paintings or poetry.

—Lawrence P. Karper

In 2001, the Institute of Medicine published their “Crossing the Quality Chasm: A New Health System for the 21st Century,”1 which followed its previous work entitled “To Err is Human: Building a Safer Healthcare System.”2 These seminal works called for improving the US health care system by requiring the development of evidence-based strategies derived from the best-available scientific knowledge. Additional suggestions from the Institute of Medicine included recommendations that the fundamental principles of health care delivery should not vary illogically between facilities or even ideally, from one clinician to another.

We are living in an unprecedented era of information and data sharing, yet the dissemination and implementation of scientific evidence into clinical practice remains astonishingly inconsistent. The systematic and timely implementation of evidence-based practices continues to present a daunting clinical challenge. The work of Balas and Boren3 estimating that “it takes 17 years to turn 14% of evidence into meaningfully improved patient care” resonates even more profoundly today, 18 years after it was published. Thus, the gap between “care that is” and “care that should be” remains wide, permitting patients and dollars to fall through a gap and into the chasm.

Encouragingly, the investments in dissemination and implementation research by various federal agencies, including the National Institutes of Health, the Agency for Healthcare Research and Quality, and Centers for Medicare and Medicaid Services (CMS) Innovation Center, have yielded important insights into methods of influencing an individual physicians’ practice and improve adherence to recommended practices. Early implementation science research was based on the implicit assumption that an individual physician’s behavior and clinical practices were driven primarily by information, knowledge, and education.4 Accumulating evidence suggests that such passive methods have limited effectiveness and points to the emerging importance of “professional norms” in influencing physician practices.5,6 Acceptance of evidence-based practice is better received from “social influence” models, such as opinion leader methods, academic detailing, and related approaches, rather than approaches based on rational, analytical decision-making.7

Professional standards promoted by physician peers and societies encounter less resistance than efforts promoted by insurers and governmental bodies8 that may be perceived to be coercive or not aligned with the individual physician–patient relationship. Therefore, physicians’ representative specialty societies have a responsibility to identify highly impactful and effective clinical priorities with significant economic benefit on which to focus their evidence-based practices efforts. Once identified, those societies need to use their resources to target and support individual or teams of clinicians by providing advocacy, support, and knowledge tools for consistent adoption of evidence-based practices. As of the writing of this editorial, CMS has earmarked $30M in grant monies to assist in developing quality measures for the Quality Payment Program (part of the Medicare Access and Children’s Health Insurance Program Reauthorization Act) by “such entities that may include clinical specialty societies, clinical professional organizations, … independent research organizations, health systems, and other entities engaged in quality measure development.”9 By inviting specialty societies to the quality measure development table, CMS and other payers acknowledge that the real drivers of quality and cost are physician practices and that social norms drive human behavior more effectively than fiscal incentives.9

In 2013, the Society of Cardiovascular Anesthesiologists (SCA) began discussing the creation of a program targeted towards improving the care of cardiac surgical patients by enhancing appropriate applications of currently accepted clinical best practices. These initial efforts resulted in a restructuring of past and creation of new SCA Committees. At the 2015 SCA Annual Meeting in Washington, DC, the SCA announced the formation of a new Quality and Safety Leadership Committee including its subcommittee on Clinical Practice Improvement (CPI).

The charge of this SCA CPI Committee is not to create new health care guidelines, but rather to organize, synthesize, and distill already existing complex and comprehensive guidelines, consensus statements, and recommendations regarding optimal practices in cardiac surgery into succinct and easily accessible compilations of educational materials to be used by cardiac surgery teams. Once health care guidelines are summated, the secondary goals are to disseminate the information and then assess these efforts on influencing application of clinical guidelines and the impact on clinical outcomes. It is expected that further revising, updating, and reevaluating CPI content will be required as new topic Guidelines and Consensus Statements are published. The SCA hopes to evaluate the effectiveness and influence of CPI summation documents on the standard implementation of guidelines between medical facilities and their cardiac surgical teams. The SCA CPI initially developed 3 working subgroups: (1) perioperative atrial fibrillation, (2) blood product conservation, and (3) postoperative cognitive dysfunction. These subgroups have been selected because of their perceived greatest initial impact on quality of care in cardiac surgical patients. In establishing these working subgroups, efforts were made to include representation of SCA members worldwide in both private and academic practice, and to coordinate with the members of other societies including the Society of Thoracic Surgeons and the European Association of Cardiothoracic Anesthesiology.

The “SCA/EACTA Practice Advisory for the Manage ment of Perioperative Atrial Fibrillation in Patients undergoing Cardiac Surgery” published in this month’s issue of Anesthesia & Analgesia highlights the work of the first SCA CPI subgroup authored by Muehlschlegel et al10 and focuses on evidence-based care for the prevention of perioperative atrial fibrillation. Efforts were made to develop the content to be readily accessible, easy to use at the point of care, and algorithmic without being rigidly prescriptive.

Increasingly, clinicians have come to recognize that there is an intermediate step in human behavior between “the what to do” and “the do,” and that is “the how to implement the do.” The intended purpose of the SCA CPI Committee is to facilitate the implementation of practice advisories by creating and promoting “the how to implement the do” content using accessible modern information platforms. The SCA CPI Committee is committed to continue serving its membership and the patients for whom they provide care.

While updated revisions to CPI advisories will be provided, the initial purpose of this content, as published in this issue of Anesthesia & Analgesia, is to provide a resource for practitioners to address a primary question pertaining to a commonly encountered, perioperative medical problem: “How do you handle A Fib prophylaxis at your institution?” Moving forward, the SCA CPI Committee is working to provide access of this information with a variety of portals including point-of-care algorithms, webinars, podcasts, social media platforms, mobile applications, and electronic medical record code, with the goal of increasing dissemination by establishing professional social practice “Tool Kits” for a particular area of clinical care. Eventually, our goal is to provide the means to collect evidence on the impact of such an approach on implementation of guidelines. Ultimately, the credibility, integrity, and sustainability of academic societies will depend on their ability to optimize patient care by creating and disseminating practical solutions to clinical questions that can be consistently implemented to improve health care quality and narrow the gap between care that is and care that ought to be.

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DISCLOSURES

Name: Nanette M. Schwann, MD, FAHA.

Contribution: This author helped author and edit the manuscript and helped with editorial content.

Name: Ray H. Engstrom, MD.

Contribution: This author helped author and edit the manuscript and helped with editorial content.

Name: Stanton K. Shernan, MD.

Contribution: This author helped author and edit the manuscript and helped with editorial content.

Name: Bruce A. Bollen, MD.

Contribution: This author helped author and edit the manuscript and helped with editorial content.

This manuscript was handled by: Roman M. Sniecinski, MD.

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REFERENCES

1. Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. 2001. Washington, DC: National Academies Press (US); Available at: https://www.ncbi.nlm.nih.gov/pubmed/25057539. Accessed October 12, 2018.
2. Kohn LT, Corrigan JM, Donaldson MS; Institute of Medicine (US) Committee on Quality of Health Care in America. In: To Err Is Human: Building a Safer Health System. 2000. Washington, DC: National Academies Press (US); Available at: https://www.ncbi.nlm.nih.gov/pubmed/25077248. Accessed October 12, 2018.
3. Balas EA, Boren SA. Bemmel J, McCray AT. Managing clinical knowledge for healthcare improvement. In: Yearbook of Medical Informatics. 2000:Stuttgart, Germany: Schattauer, 65–70.
4. Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance. A systematic review of the effect of continuing medical education strategies. JAMA. 1995;274:700–705.
5. Mostofian F, Ruban C, Simunovic N, Bhandari M. Changing physician behavior: what works? Am J Manag Care. 2015;21:75–84.
6. Johnson MJ, May CR. Promoting professional behaviour change in healthcare: what interventions work, and why? A theory-led overview of systematic reviews. BMJ Open. 2015;5:e008592.
7. Mittman BS, Tonesk X, Jacobson PD. Implementing clinical practice guidelines: social influence strategies and practitioner behavior change. QRB Qual Rev Bull. 1992;18:413–422.
8. Hayward RS, Guyatt GH, Moore KA, McKibbon KA, Carter AO. Canadian physicians’ attitudes about and preferences regarding clinical practice guidelines. CMAJ. 1997;156:1715–1723.
10. Muehlschlegel JD, Burrage PS, Ngai JY. Society of Cardiovascu lar Anesthesiologists/European Association of Cardiothoracic Anaesthetists Practice Advisory for the management of perioperative atrial fibrillation in patients undergoing cardiac surgery. Anesth Analg. 2019;1281:33–42.
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