Using Evidence in Clinical Care to Improve Patient Outcomes

Earlier this year, before the pandemic absorbed the flow of time like a black hole, I wrote an article on the use of evidence-based medicine in clinical care (bit.ly/MODhcp0120). That article included discussion of the concepts of patient-centered care and shared decision-making.¹ As promised, this next installment reviews evidence and strategies for how to effectively apply these concepts in the clinical setting to improve health in your patient population.

EVIDENCE-BASED CARE

The concept of evidence-based care is the use of scientific research to inform delivery of quality care to people of all ages. Patient-centered care, an essential component of quality health care, is defined as “care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions.”²

Shared decision-making, as discussed in my previous article, is a proactive way to incorporate these concepts. Shared decision-making requires a working knowledge of what the best available evidence is and where to find it for translation into patient care.³ A clinically useful definition of evidence-based health care is “the conscientious use of current best evidence in making decisions about the care of individual patients or the delivery of health services.”⁴

DISCOVERING EVIDENCE

Much attention has been placed on synthesizing health-related evidence and making it accessible to health care providers in recent decades. These efforts have been driven by many factors, including the increasing volume of clinical knowledge, rising health care costs, evolving patient expectations, and the growth of health technology.⁵Knowledge discovery—the process of extracting useful knowledge from data—is fundamental to having the best scientific research available for use in health care.

Evidence comes in many forms and strengths. Investigative presentations can include meta-analyses; systematic reviews; randomized controlled trials; comparative effectiveness and outcomes assessments; cohort (retrospective or prospective), case-control (retrospective), case report/case series, and diagnostic studies; nonrandomized trials; review and position papers; published abstracts and conference presentations; and expert opinion.

ASSESSING EVIDENCE

The strongest level of evidence is currently acknowledged to reside in meta-analyses and their related systematic reviews. A systematic review addresses a specific question through rigorous collection and summarization of all identified evidence that meets predefined criteria. If enough studies and data are available, a meta-analysis can be performed using statistical methods to combine and summarize study results that are statistically stronger than any one single study. Not all systematic reviews include meta-analysis, but all meta-analyses are found in systematic reviews.

Other evidence and study types, due to their design, population and sample sizes, reference standards, and/or risk of biases, provide lower levels of strength for determining specific clinical recommendations.

Of special relevance for clinicians are evidence-based clinical guidelines. These documents provide patient care recommendations based on a rigorous formal systematic review and assessment process, synthesizing all available forms of evidence to address a specific health-related question or topic. In eye care, guidelines have been promulgated relevant to the diagnosis, management, and treatment of patients with a variety of eye- and vision-related health conditions.

Historically, clinical guidelines were often developed as consensus documents, heavily drawing from expert opinion, or as review documents with little to no objective analysis and little if any indication of recommendation strength. Today, the more nuanced recommendations provided by proper evidence-based guidelines can better serve patients and care providers, improve clinical decision-making, and contribute to optimal health outcomes.

DEVELOPING GUIDELINES

There are many approaches to assessing the quality of evidence. In the United States, guidance for conducting high-quality systematic reviews and developing trustworthy clinical guidelines is offered by the National Academies of Sciences, Engineering, and Medicine (NASEM; formerly the Institute of Medicine). This guidance serves as the standard for these types of evidence synthesis.

According to both NASEM and the Agency for Health Research and Quality (AHRQ), the following criteria must be met for clinical guidelines to be recognized as evidence-based:

• They should be based on a systematic review of the existing evidence.
• They should be developed by a knowledgeable, multidisciplinary panel of experts and representatives from key affected groups.
• They should be based on an explicit and transparent development process to minimize bias and conflicts of interest.
• They should be graded for both quality of evidence and strength of recommendations.
• They should contain articulated and precise clinical recommendations in a standardized form.
• They should be reviewed through an external and peer-review process.
• And they should be reviewed every 2 to 5 years and revised when new evidence warrants.

To address these criteria in its own guidelines, the American Optometric Association (AOA) began developing an evidence-based process in 2012. The AOA’s 14-step process (Table) for evidence-based guideline development aligns with national quality standards for trustworthy clinical guidelines.⁶

Many professional groups have adopted or developed individualized protocols to rate the quality of individual studies and the strength of recommendations based on a body of evidence for their own guideline recommendations. An easily accessible example of an effective evidence-grading system can be found in the AOA’s evidence-based clinical practice guideline, Eye Care of the Patient with Diabetes Mellitus, Second Edition.

The AOA’s hierarchical grading system assigns an A, B, C, or D grade to the strength of each reviewed reference.⁶ Another approach, used by our colleagues in family medicine, is the Strength of Recommendation Taxonomy.⁷

As with reading studies in the literature, a critical eye is needed to identify the rigor of the process used to develop clinical recommendations and the quality of the evidence used to support them. The Cochrane Library is a widely known resource for high-quality evidence. Cochrane developed its own rigorous protocol for evidence synthesis, and the organization has generated many systematic reviews and related meta-analyses when appropriate with contributors from more than 130 countries worldwide. Cochrane’s stated mission is “to promote evidence-informed health decision-making by producing high-quality, relevant, accessible systematic reviews.”

Many other reliable resources exist, including those from the AHRQ, online resources such as the Dartmouth Library, and the AOA’s online clinical guidelines center.⁸

USING EVIDENCE

In order to be used, evidence must be accessible. Shared decision-making requires it. Health information technology today allows clinical guidelines and other clinical decision-making tools to be incorporated into electronic health record platforms. Even if your electronic health record system does not support such incorporation, you can keep links to important evidence-based resources handy in exam rooms or close by on a tablet or phone in most patient care settings.

Using the information gathered in peer-reviewed, evidence-based optometric clinical guidelines is vital to serving the nation’s health. It also supports the profession and practice of optometry in multiple ways.

The AOA’s Evidence-Based Optometry Committee devotes nearly 3,000 hours to each guideline it develops. Following its 14-step development process, the committee reviews and grades thousands of abstracts, papers, and studies for each document. The result is a series of thorough, peer-reviewed guidelines that can be incorporated throughout training and practice.

For future and new doctors of optometry, schools and colleges of optometry and residency programs can enhance their clinical and didactic curricula by incorporating the latest eye- and health-related patient care recommendations into educational programming at no cost.

For frontline primary eye care providers, the AOA guideline recommendations⁹ are stratified by subject and strength of evidence. Busy eye doctors also can quickly consult the AOA’s green Action Statement Profiles highlighting key clinical considerations.

For researchers and educators, these Action Statement Profiles include information on areas where gaps in evidence exist and additional investigation is needed.

For the profession of optometry, evidence-based guidelines elevate the value of optometric care in the eyes of other health care colleagues and the public. Evidence helps us take the best possible care of our patients, and that is a population health goal worthwhile for everyone to adopt.