John P. Holland, MD, MPH Past-President, ACOEM Chair, Guidelines Steering Committee
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Transcript of John P. Holland, MD, MPH Past-President, ACOEM Chair, Guidelines Steering Committee
04/22/23 02:49
ACOEM Practice Guidelines Perspectives on their use in guiding clinical care and utilization management
John P. Holland, MD, MPHPast-President, ACOEM
Chair, Guidelines Steering Committee
California Division of Workers’ Compensation
12th Annual Educational Conference
February 23 - 24, 2005 – Los AngelesFebruary 28 – March 1, 2005 – Oakland
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
Presentation Overview
Overview and Current Issues1. ACOEM perspective and
why EBM matters
2. Use of evidence in developing APGs
New Initiatives
1. APG Insights – newsletter
2. Utilization Management Tool (UMT)
3. Plans for the next generation of clinical practice guidelines
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The ACOEM Perspective -
and why evidence-based medicine is important
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
The ACOEM Perspective
Our core mission - Promote the health and productivity of
workers, workplaces and the environment
Our core values - Use science to guide practice, programs
and policy Promote fairness for individuals, employers
and society Use processes that are inclusive, transparent
and rationally consistent
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
What is evidence-based medicine (EBM)?
“Evidence-based medicine is the conscientious,
explicit, and judicious use of current best
evidence in making decisions about the care
of individual patients.”
- David Sackett
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
Evidence-based medicine
Evidence-based Medicine
Gathering medical information
Evaluating quality of medical information
Making medical decisions using best evidence
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
Elements of EBM - identify relevant best evidence Define clinical question to be answered
(for a specific clinical situation)
Find best scientific evidence relevant to the specific clinical question (using systematic methods)
Rely on best evidence to guide clinical decision-making
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
Elements of EBM - identify relevant best evidence
Original evidence clinical epidemiology (e.g. clinical) trials descriptive epidemiology outcomes research / economic studies
Literature synthesis / analysis systematic literature reviews / meta-analyses clinical practice guidelines cost-effectiveness studies
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
Elements of EBM - focus on clinical outcomes
Clinical outcomes (things that matter to patients and families)
survival impairment / disability / disfigurement symptom severity quality of life (QOL) cost / convenience
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
Elements of EBM - use standard measures of effect
Evaluate therapies using standard measures:How does it affect rate, degree or timing of:– Physical impairment, disfigurement or death – Return to normal functioning– Symptom resolution– Potential harms (from therapy)– Total costs (for patient, employer and society)
Allows comparisons of benefits and harms of different clinical methods
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
Elements of EBM - assess likely benefits / harms
Evaluate clinical methods on benefits / harms– Beneficial – Likely to be beneficial– Trade off between benefits and harms– Unknown effectiveness– Unlikely to be beneficial– Likely to be ineffective or harmful
Promotes informed decision-making by clinicians and patients
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
Elements of EBM - base decisions on best evidence Find best scientific evidence that is
applicable to the specific clinical situation – individual patient’s clinical situation– program or policy decision
Use evidence to guide decision-making– does the likelihood of benefit outweigh likelihood
of harm enough to justify the cost?– same question applies to individual and society
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
EBM is important because - provides a science-based method for
Improving physician practice– increase effectiveness / decrease harms
(better clinical outcomes / cost-effectiveness) Increasing consumer knowledge
– understand potential benefits / harms
Building quality into healthcare systems– using practice guidelines, quality indicators
Guiding government / employer policies– guide programs / policies on healthcare
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
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Use of Evidence in Developing
the ACOEM Clinical Practice Guidelines (APGs)
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
What are clinical practice guidelines?
Clinical practice guidelines are
recommendations for clinicians and
consumers about optimal and appropriate
care for specific clinical situations
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
Formal or informal guidelines are the basis for all clinical practice
Basis for most clinical decisions
Foundation of clinical teaching
Mental short-cuts and memory aids for common or complex problems
Primary method to evaluate care patterns and monitor standards of care
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
Types of guidelines - major focus
clinical assessment / treatment – management of cardiac arrest (ACLS)
risk assessment / prevention – drugs to use in pregnancy (ACOG)
administrative – insurance pre-approval for surgery
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
When are guidelines needed ?
Institute of Medicine (IOM) criteria – clinical practice guidelines are useful when:
– the problem is common or expensive
– there is great variation in practice patterns
– there is enough scientific evidence to determine appropriate and optimal care
(IOM , 1992)
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
Types of guideline development approaches Single author - expert opinion
Single author - systematic literature review
Consensus panel using expert opinion only
Consensus panel using evidenced-based approach (AHCPR methodology)
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
Steps in developing guideline recommendations define clinical questions of interest develop summary of evidence on:
– clinical efficacy (potential benefits)– potential harms / projected costs
weigh likelihood of benefit versus likelihood of harms, and consider costs
develop finding / recommendation statements document all aspects of the process
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
Evidence-based guidelines - need to explicitly document
methodology and assumptions evidence reviewed summary of findings decision-making rules for recommendations rationale for each conclusion and
recommendation statement
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
Types of guideline statements
Based on AHCPR guidelines, the types of guideline statements are:
Recommendation for use
Option for use
Recommendation against use
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
Strength of evidence ratings for guideline recommendations
A = Strong research based evidence– multiple relevant, high quality studies
B = Moderate research based evidence– one relevant, high quality study
C = Limited research based evidence– one adequate study, somewhat relevant
D = Panel opinion – based on information not meeting criteria for A-C
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
Criteria for determining is a study contains “High quality” evidence Clinical epidemiology is the study of the
effectiveness of clinical assessment and treatment methods
There is general consensus among experts on what constitutes a high quality study – but specific criteria vary on subtle details
APGs relied on criteria for determining high quality studies used by the AHCPR low back guideline and Cochrane Reviews
ACOEM Practice Guidelines, 2nd Ed., page 501)
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ACOEM New Directions -
APG Insights
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
APG Insights - newsletter
Newsletter devoted to discussing issues relevant to use of the ACOEM Practice Guidelines (APGs)
Separate editorial board Anticipate about 6 issues per year First issue was in fall of 2004,
next issue in March 2005 For information go to acoem.org
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
APG Insights - purpose
APG Insights will Provide suggestions and examples on how APGs can
be used in clinical care / utilization management Provide summaries of scientific evidence (systematic
reviews) on clinical topics relevant to the APGs
APG Insights will not Explain or justify how APG were developed (APGs
must speak for themselves) Be a revision or update of the guideline
(no presumption of correctness in California)
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
APG Insights – Fall 2004- APG guidance on chronic conditions States “Unequivocally” that APGs do apply to
conditions after 90 days (chronic conditions)
APGs - “Mostly focus on the first 90 days following workplace injury because approximately 90% of injuries are resolved during this time period.”
Chapters 1-7 of APGs give general approach for assessment and treatment of injured workers - “These basic components remain constant
throughout the life of the claim”
Chapter 6 deals extensively with chronic pain (generally defined as pain lasting over 3-6 months)
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ACOEM New Directions -
Utilization Management Tool (UMT)
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
Utilization Management Tool
Purpose of UMT is to provide Accurate interpretation of APG recommendations
claims staff can rely upon in making decisions
Consistent interpretations to reconcile perceived inconsistencies within APG
Easy to use tool to foster efficient and consistent utilization management based on APG
Create written summary of relevant APG guidance relied upon in making claim decision (based on UMT)
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ACOEM New Directions -
Next Generation of Clinical Practice Guidelines
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
Next Generation of Clinical Practice Guidelines ACOEM is committed to moving to the “next level” in
working to develop a new generation of clinical practice guidelines
We continue to learn about how guidelines are best used in WC settings
We are committed to increasing scientific rigor, documentation and usefulness in future guideline development efforts
In our work on developing a new generation of practice guidelines – we are committed to following our core mission and core values in these efforts
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
The ACOEM Perspective
Our core mission - Promote the health and productivity of
workers, workplaces and the environment
Our core values - Use science to guide practice, programs
and policy Promote fairness for individuals, employers
and society Use processes that are inclusive, transparent
and rationally consistent
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References Evidence-based medicine and practice guidelines
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
References – Evidence-based medicine and practice guidelinesBook chapters and journal articles
1. American College of Occupational and Environmental Medicine (2004). ACOEM Clinical Practice Guidelines, 2nd Edition. Glass L (Ed.). (Beverly Farms, MA; OEM Press).
2. Bigos SJ, et. al. (1994) U.S. Agency for Health Care Policy and Research (AHCPR) Clinical Practice Guideline #14: Acute low back problems in adults. Pub. 95-0642 (U.S. Department of Health and Human Services, Public Health Service, Rockville, MD).
3. Holland JP. (1995) Developing evidence-based clinical practice guidelines. Current Opinion in Orthopedics. 6: 63-69.
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
References – Evidence-based medicine and practice guidelinesBook chapters and journal articles (continued)
4. Holland JP, Holland CL, Webster JS, Bigos SJ. (2003) How to critically evaluate the literature on low back problems: The foundation for an evidence-based approach to care. Seminars in Spine Surgery. 15: 54-67.
5. Institute of Medicine, Committee on Clinical Practice Guidelines. (1992) Guidelines for Clinical Practice: From Development to Use. Field M, Lohr K (Eds). (Washington, DC; National Academy Press).
6. Sackett D, Haynes R, Guyatt G, et al. (1991). Clinical Epidemiology: A Basic Science for Clinical Medicine, 2nd Edition. (Boston, MA; Little, Brown).
John P. Holland, MD, MPHJohn P. Holland, MD, MPH
References – Evidence-based medicine and practice guidelinesBook chapters and journal articles (continued)
7. Sackett D, Straus S, Richardson W, et al. (2000). Evidence-based Medicine: How to Practice and Teach EBM. (New York, NY; Churchill Livingstone).
Websites
8. www.acoem.org - ACOEM’s website. For information on APG Insights, a newsletter on issues relevant to the ACOEM Clinical Practice Guidelines.
9. www.cochrane.org - The Cochrane Collaboration website; a source for systematic reviews on medical intervention