Causes of and Potential Solutions to the High Cost of Health Care

Clinical Guidelines: Building Blocks for Effective Chronic Illness Care

On October 10, 2003, Jean Slutsky, P.A., M.S.P.H., made a presentation in a Web-Assisted Audioconference at Session 2, which was entitled Reining in the Cost of Chronic Illness.

This is the text version of Ms. Slutsky's slide presentation. Select to access the PowerPoint® Slides (836 KB).

Clinical Guidelines: Building Blocks for Effective Chronic Illness Care

Jean Slutsky, P.A., M.S.P.H.
Director, National Guideline Clearinghouse
Project Director, US Preventive Services Task Force
U.S. Agency for Healthcare Research and Quality

Slide 1

Finding the Evidence.

• Approximately 8,000 completed references are added to MEDLINE each week (over 400,000 added per year).
• Too much for any one person to evaluate.
• Uncertainty results in:
  • Variations in care.
  • Under and over utilization of services.

Slide 2

Putting Evidence into Practice

It may take as long as 17 years for original research to be put into routine clinical practice.

Source: Balas EA, Boren SA. Managing Clinical Knowledge for Health Care Improvement. Yearbook of Medical Informatics. Schattauer, 2000: 65-70.

Slide 3

Documented Variation in Treatment of Congestive Heart Failure.
Bar graph of 69 hospitals in 5 states comprising 2077 patients with Congestive Heart Failure.
Prescribed ACE ranged from 23 percent to 79 percent.
Counseled on salt ranged from 8 percent to 64 percent.

Source: Effective Clinical Practice, March/April 2000.

Slide 4

Under-use of Beta-blockers

• Despite strong evidence that use of beta-blockers following acute myocardial infarction (AMI) decreases morbidity and mortality, they are substantially under used in the elderly.
• Beta-blocker prophylaxis after AMI is one of the most scientifically substantiated, cost-effective medical services. Their use decreases cardio-vascular mortality and reinfarctions, and increases survival by 20 percent to 40 percent.
• Under use leads to excess 2-year mortality and re-hospitalization for cardiovascular disease.

Slide 5

Under-use of Beta-blockers (cont'd)

• Only 21 percent of eligible New Jersey Medicare beneficiaries received beta-blocker therapy following their heart attack.
• Calcium channel blockers were used almost 3 times as often despite a lack of evidence that they decreased mortality.
• Patients on beta-blockers were re-hospitalized 22 percent less often and their mortality rate was 43 percent lower than non-recipients.
• Patients receiving calcium channel blockers instead of beta-blockers doubled their risk of death.

Source: JAMA January 8, 1997;277:115-21.

Slide 6

Examples of Quality of Chronic Health Care

• 52 percent of elderly adults received a flu shot in 1993.
• 33 percent of hospitalized elderly discharged on an anti-depressant were on a dose below recommended level.
• 49 percent of diabetic adults had dilated eye exam in past year .
• 43 percent of patients who should have received coronary angiography received it within 3 months.

Slide 7

Chronic Care Management

Do the RIGHT thing to the RIGHT patient at the RIGHT time.

Slide 8

Guidelines Can Improve Clinical Decisions

Clinical guidelines based on critical appraisal of scientific evidence (evidence-based guidelines) clarify which interventions are of proven benefit and document quality of supporting data.

• Alert clinicians to interventions unsupported by good science.
• Reinforce the importance and methods of critical appraisal.
• Call attention to ineffective, dangerous, and wasteful practices.

Source: BMJ 1999;318:517-30 (20 February).

Slide 9

Images of the main page for AHRQ's National Guideline Clearinghouse™.

URL:
http://www.guideline.gov

Slide 10

Images of AHRQ's National Guideline Clearinghouse™ Web pages, continued.

Slide 11

Images of AHRQ's National Guideline Clearinghouse™ Web pages, continued.

Slide 12

Images of AHRQ's National Guideline Clearinghouse™ Web pages, continued.

Slide 13

In Summary

• Chronic illness care should be based on the best available evidence.
• "Stop, look, and listen" and make sure that you know what you are using: who developed it, how good is the information, and is it current.
• www.guideline.gov provides access to evidence-based guidelines.

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Current as of July 2003

Internet Citation:

Clinical Guidelines: Building Blocks for Effective Chronic Illness Care. Slide Presentation by Jean Slutsky, at Web-Assisted Audioconference, "Causes of and Potential Solutions to the High Cost of Health Care." Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/ulp/hicosttele/sess2/slutskytxt.htm

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