Teaching Evidence-based Medicine in a Managed Care Setting: From Didactic Exercise to Pharmacopolicy Development Tool

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The American Journal of Managed Care, September 2005, Volume 11, Issue 9

Objectives: To implement a residency-based program for theteaching of evidence-based medicine in an Israeli HMO and toincorporate this effort into the HMO's routine drug policy formulationprocess.

Methods: Residents and preceptors participating in the familypractice residency program in The Leumit Health Fund, 1 of the 4HMOs operating in Israel, were invited to participate in a workshopfor the formulation of guidelines for antibiotic treatment of thecommon infectious diseases encountered in primary care. The participantswere allocated to teams consisting of a preceptor (anattending physician) and a resident physician, with each teamchoosing a different disease to analyze. Upon completion of theprogram, a questionnaire was sent to all residents and preceptorswho participated in the workshop to evaluate attitudes concerningthe outcomes of the program.

Results: Guidelines for the treatment of 14 infectious diseasescommonly seen in the primary care setting were formulated. Theprogram was accepted by the participants, who ultimately cooperatedwith the relevant HMO stakeholders in the formulation of officialHMO policies for drug prescribing.

Conclusion: The utilization of family practice residents is a feasiblemethod of formulating in-house clinical practice guidelinesfor a managed care setting. The program was mutually beneficialfor both the residents and for the stakeholders in the HMO.

(Am J Manag Care. 2005;11:570-572)

Clinical practice guidelines (CPGs) are becomingincreasingly common in the clinical setting.1-3Clinicians, policymakers, and payers see CPGsas tools for making healthcare more consistent and efficientand for closing the gap between what clinicianspractice and what scientific evidence supports.1Accordingly, an increasing number of medical schoolsand residency programs are instituting curricula forteaching the principles and practice of evidence-basedmedicine (EBM),2 utilizing various teaching techniquessuch as short courses,3,4 workshops,5 structured programswithin clinical clerkships,6 and formulation oflocal, residency-developed guidelines.7 Although theseendeavors have included hospital and community settings,the unique potential of the managed care setting asa teaching platform for EBM has yet to be realized.

This study had 2 objectives. The first was to explorethe feasibility of implementing a family practice residency-based program for the teaching of EBM in anIsrael HMO. The second was to investigate the possibilityof incorporating this effort into the HMO's routinedrug policy formulation process.

METHODS

This study was conducted in The Leumit HealthFund of Israel. Residents and preceptors (attendingphysicians) participating in this HMO's family practiceresidency program were invited to participate in a workshopfor the formulation of evidence-based guidelines inthe community setting. The workshop included 3 sessionsconducted over a 12-month period and was coordinatedby the director of the residency program, aprofessor of family medicine.

To concentrate on an area in which the primary carephysician is the exclusive clinical decision maker, theworkshop was limited to the formulation of CPGs for thetreatment of infectious diseases commonly encounteredin primary care. During the first session, the directorintroduced the subject of CPGs and lectured on theevaluation of published evidence. He then described theobjectives of the workshop and lectured on the utilizationof available data sources for the project. The participantswere allocated to teams consisting of apreceptor and a resident, with each team choosing a differentdisease to cover. Each team conducted a systematicreview of the literature on their subject via Medlineand Cochrane database searches. Current guidelinesfrom other clinical settings, both international andIsraeli, also were studied. When feasible, HMO laboratorydata on pathogen antibiotic resistance patterns wereanalyzed. Like similar programs,8 this workshop includeda pharmacist (in this case, the HMO's pharmacoepidemiologist)as a preceptor to provide informationregarding current drug utilization patterns, drug costs,and product availability.

During the second session, preliminary drafts of theguidelines were presented alongside the evidence onwhich they were based. Questions, comments, and suggestionsfor improving or modifying the guidelines wererequested. Subsequently, revised versions were submittedto the project coordinator for review and were forwardedto all participants with a request for feedback.Relevant feedback was integrated into final versions ofthe guidelines. These drafts then were submitted to theHMO's infectious disease consultant and the MedicalDivision for evaluation.

The third and final session, although still chaired bythe project coordinator, was conducted with the declaredpurpose of reaching consensus amongst all relevantstakeholders within the HMO for a designated antibioticpolicy. Therefore, the assistant CEO for medicine, theHMO's infectious disease consultant, and the chairman ofthe Medicines Committee attended. After the projectcoordinator presented the amended version of a guideline,feedback was requested from the infectious diseaseconsultant regarding the clinical aspects of the disease inquestion, and from the chairman of the MedicinesCommittee concerning the pharmacoeconomic ramificationsof the drug therapies recommended. At this point,the floor was opened for discussion, and final decisionswere made regarding the guideline being discussed. Theproject coordinator then prepared the final versions ofthe guidelines for publication and promulgation to all primarycare physicians working in the HMO.

On completion of the program, a questionnaire wassent to all workshop participants. This self-reportedquestionnaire was based on a previously publishedquestionnaire,7 modified by the researchers to includequestions pertaining to attitudes about the decision-makingprocess in the managed care setting and aboutthe treatment of infectious diseases in the community.It consisted of 10 questions using a 5-point Likert scale(1 = strongly agree, 5 = strongly disagree) to measuredegree of physician agreement.

RESULTS

Twelve residents and 9 preceptors participated in theworkshop. In addition to the 3 sessions, each participantspent between 5-10 hours on independentresearch. The participants succeeded in formulatingguidelines for the following 14 diseases: acute bronchitis,acute gastroenteritis, acute otitis media, acutesinusitis, bacterial endocarditis, cellulitis, community-acquiredpneumonia, erysipelas, folliculitis-furunclecarbuncle,gonorrhea, impetigo, pelvic inflammatorydisease, tonsillopharyngitis, and urinary tract infection.After completion, the guidelines were adopted by theMedical Division and were distributed to all primarycare physicians employed by the HMO.

Eleven residents and 9 preceptors returned the completedquestionnaire for a response rate of 95.2%. Thesurvey questions and answers appear in the Appendix.The participants generally found the workshop to be apositive experience in which they learned practical skillsin EBM (mean score = 1.70), and which qualified them towrite CPGs (mean score = 1.95). The participants generallybelieved that they would use the guidelines in theirpractices (mean score = 1.70) and thought that the workshopimproved their capabilities for providing qualitycare to their patients (mean score = 1.50). The participantsresponded that the experience strengthened theirunderstanding of the decision-making process for settingdrug policies in the HMO (mean score = 1.75) and thatthey thought that participating in the process strengthenedtheir confidence in the policies that resulted (meanscore = 1.95). Concerning the program itself, the participantsthought that they had adequate access to the necessaryinformation sources (mean score = 1.90), andshowed willingness to participate again in the developmentof CPGs (mean score = 1.95) and in future workshopsconducted in this format (mean score = 1.95).

DISCUSSION

This program, which was initially implemented as anacademic exercise for the teaching of EBM to familypractice residents, ultimately was utilized by the hostingmanaged care system for the formulation of policiesfor drug prescribing. Platt et al have commented thatHMOs are distinguished from other healthcare systemsby unique attributes such as defined patient populations,unique data capabilities, and their organizationalcapabilities and access to both clinicians and members.9These unique qualities, which are inherent to the managedcare environment, coalesced in this exercise tocreate a platform both for development of methodologiesfor drug-policy analysis and for hosting academicprograms.

The findings of this study demonstrate that the HMOaugments its potential to act as an "organizational laboratory"when it functions as a teaching environment,because it draws on a cadre of qualified professionalswith the motivation to participate in such endeavors.The degree of willingness to participate in future programsobserved in the survey is significant in that itindicates that the HMO can indeed rely on this valuableresource in the future.

CONCLUSION

By incorporating family practice residents led by anacademic coordinator into the drug policy decision-makingprocess, the HMO realized its potential as aunique teaching setting while benefiting from a previouslyuntapped source of professional manpower. Theimplementation of this program provided mutual benefitsfor both the participating residents and the stakeholdersin the HMO, and may serve as a template forfuture efforts in the managed care setting.

From Leumit Health Fund, Tel-Aviv, Israel (NRK, YF, DAW, AW, E Kitai); HadassahMedical Organization School of Public Health, The Hebrew University of Jerusalem,Jerusalem, Israel (NRK); the Department of Family Medicine, Sackler Faculty of Medicine,Tel Aviv University, Tel Aviv, Israel (E Kahan, E Kitai); and the Department of InfectiousDiseases, Assaf-Harofeh Medical Center, Zrifin, Israel (ABY).

Address correspondence to: Natan R. Kahan, RPh, MHA, Leumit Health Fund, 23Schprintsak St, Tel-Aviv, 64738 Israel. E-mail: nkahan@leumit.co.il.

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