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Wednesday Feb 15, 2017

Why Do We Adopt Evidence-based Data at a Snail's Pace?

Branch Rickey may have been the most pioneering figure in baseball history, but his success, at one point, seemed unlikely.

After a short playing career and two lackluster stints as a manager, Rickey found his niche as an executive for the St. Louis Cardinals, Brooklyn Dodgers and Pittsburgh Pirates from 1919 to 1955. Rickey is perhaps best remembered as the man who had the courage and vision to integrate Major League Baseball, bringing Jackie Robinson to the Dodgers in 1947. But among his many other innovations, Rickey started the first farm system, a series of minor league teams that funnel talent to the major league club; invented the batting helmet; and was instrumental in getting Major League Baseball to expand to new markets in 1961.

One of his biggest, yet lesser known, advances had to do with the use of novel statistical analyses to gain an advantage. These innovations were made public in the 1950s, but they did not come into widespread use in the major leagues for more than 50 years.

With the assistance of baseball's first full-time statistician, Allan Roth, Rickey developed many new statistics, such as on-base percentage and slugging percentage. These are now ubiquitous in baseball circles as they are most strongly correlated with scoring runs (or the inverse for pitchers, in preventing them), and thus winning games.

So why did it take more than 50 years for every other team to catch on? On the face of it, it seems ludicrous. Rickey didn't keep these tools a secret. In fact, he wrote an entire article outlining the findings in Life magazine(books.google.com) in 1954. However, there are many reasons for the slow adoption of his innovations, and we see this resistance to change in health care, too.

Andrew Balas, M.D., PhD., and Suzanne Boren, M.H.A., Ph.D., wrote that it takes, on average, 17 years for health care to adopt new evidence-based findings(www.ihi.org). (Ironically, that paper was published 17 years ago.) This seems absolutely ridiculous. Why wouldn't we want to do the best we can to help our patients? Many of the reasons are in our control, but many are not.

Here are but a sample:

Practice Inertia
Most of us practice the way we were trained. In medical school, residency and possibly fellowship, we learned certain ways to approach diagnosis and treatment of many different conditions. We often saw small, anecdotal victories or failures that reinforced these notions for us, whether based in actual scientific evidence or not. It's hard to get rid of that mentality, and it's easier to hold onto our habits than to change. But the truth is that much of what I learned in medical school is obsolete, even though I graduated just eight years ago.

Information Overload
There is absolutely no way to stay up on all of the medical advances, and that's not even considering how busy we are with our day-to-day practice. Approximately 2.5 million scientific articles are published every year(www.cdnsciencepub.com). Obviously, not all of those studies are applicable to our practice, but it is still difficult to absorb all the new knowledge we need. Also, certainly not all published research is equal, and it takes a lot of time to properly evaluate whether a study is worth applying to our practice. Addressing any potential clinical workflows to implement new practices only adds to the complexity of this barrier.

Insurance or Regulation-prescribed "Quality"
In 2015, one local insurance company began sending letters to beneficiaries offering them a gift card if they received their annual Pap smear. When patients came in, I told them they did not need a Pap smear every year based on "new" guidelines (guidelines that came out three years earlier and were supported by multiple health care organizations and advocacy groups). But patients were understandably upset because they wanted their gift cards. When I contacted the insurer about its error, the company said it would stop sending the letter to my patients. But that wasn't the issue. The insurer was endorsing old recommendations that had been proven to be unnecessary and even harmful. Oftentimes, insurers and regulators fall behind the evidence, perpetuating out-of-date knowledge. It's also more difficult when different insurers act on varying levels of evidence in their metrics.


Those who are struggling with burnout and/or clinical depression are going to be less likely to make significant efforts to improve their practice. This represents a different type of inertia than that mentioned above.

All of these barriers, and others, significantly disrupt our attempts to get our patients the best care available. This has led to a greater emphasis in translational research in recent years(www.nhlbi.nih.gov) in an effort to determine the best ways to implement new evidence-based practices. As with most issues in the complex world of health care, the situation is difficult to resolve and takes systemic reforms.

As an academic physician, I am expected to stay up on the latest research and guidelines and teach them to students and residents. One of the easiest ways that I have found to do that is through podcasts, typically listening on the ride to work. I also subscribe to services that summarize recent research findings. These can be tailored to the needs of one's practice, which it makes it even more helpful. I occasionally need to take a deeper dive into a given article or topic, but these tools provide a great starting point. For employed physicians, many larger systems can provide other opportunities to make it easier to improve our knowledge.

There also are numerous tools and resources to help us stay up-to-date through the AAFP, including journals  and CME.  The AAFP follows a rigorous process in the development of its own guidelines and in its endorsements of others so that family physicians can make decisions based on the best available evidence.

The epilogue to Branch Rickey's statistical efforts is documented in the book and movie Moneyball. Rickey's ideas have created a huge organizational and intellectual revolution in baseball in the last 10 to 15 years, with nearly all clubs now implementing the type of analyses that Rickey's Brooklyn Dodgers were doing in the 1940s. Let's hope that evidence-based medical knowledge doesn't take so long to implement.

Kyle Jones, M.D., is a faculty member at the University of Utah Family Medicine Residency Program in Salt Lake City. He is the director of primary care at the Neurobehavior HOME Program, a patient-centered medical home for those with developmental disabilities. You can follow him on Twitter @kbjones11(www.faa.gov).

Posted at 12:08AM Feb 15, 2017 by Kyle Jones, M.D.

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