Widespread Adoption of Evidence-Based Practices Is Essential for a Growing Medicare Population

May 25, 2016
Bernadette Melnyk, PhD, RN, CPNP/PMHNP, FNAP, FAAN

Evidence-Based Diabetes Management, May 2016, Volume 22, Issue SP7

When providers move from employing traditional practices to new methods that are steeped in evidence, this benefits patient health. The result is higher-quality, more affordable care, often stemming from lower rates of hospital infections, readmissions, and, in general, improved outcomes.

When providers move from employing traditional practices to new methods that are steeped in evidence, this benefits patient health. The result is higher-quality, more affordable care, often stemming from lower rates of hospital infections, readmissions, and, in general, improved outcomes. This is probably a song that most healthcare leaders have heard before.

It’s a tune that bears repeating, though, until evidence-based practices are being performed in all healthcare settings in America. Quite certainly, to raise our nation’s standard of care, particularly as the older segment of our population increases in size, providers need to embrace methods that combine scientific research, clinician expertise, and patient preferences, which directly improve quality and safety measures.

While addressing these basic tenets of evidence-based practice is said to be a high priority area for hospital leadership, our recent study in Worldviews on Evidence-Based Nursing1 shows that adoption of evidence-based practices is alarmingly low. This fact jeopardizes both the Institute of Medicine’s goal to have all healthcare decisions based in evidence by 2020,2 as well as the health of all Americans, particularly the over-65 demographic that accounts for approximately 35% of hospitalizations. Because Medicare, which generally covers adults 65 years or older and the disabled, is the primary payer for 40% of total hospital stays, change here would not only benefit this population, but would have ripple effects across healthcare.3

For many older Americans, the difference in traditional “we’ve always done it that way” practice versus evidence-based practice is magnified. Studies show that older patients are at greater risk for functional decline4 and are more susceptible to experiencing falls and delirium, and developing infections, pressure ulcers, and adverse drug reactions during hospitalization.5 Knowing these facts, and the fact that the care of adults 80 years and older is the largest expense for Medicare,6 it’s imperative that payers like Medicare incentivize evidence-based practices in hospitals and primary care settings for all providers, including physicians, physician assistants, nurse practitioners, and others, rather than continuing with age-old, traditional methods.

Imagine the following:

• What if the standards of care outlined by the American Diabetes Association, which include evidence-based practices for treating and diagnosing diabetes, were being adhered to in healthcare settings? These practices include, among others, regular foot, eye, and dental examinations and annual screening for microalbuminuria.7

• What if catheters were removed based on nurse-driven protocol, which is proven to be more efficient and leads to fewer infections than physician orders?8

• What if we ensure that intravenous catheters are not being replaced more frequently than every 72 to 86 hours? It is often an unpleasant experience for patients and is deemed unnecessary if the catheter is deemed functional and there is no inflammation present.9

• What if stable patients were encouraged to sleep, rather than woken up every 4 hours to have vital signs checked, impeding critical recovery time10

• What if, to prevent pressure ulcers, we were turning patients every 2 hours, as studies indicate is best practice?11

• What if depression screening was routinely conducted in primary care settings and cognitive-behavior therapy was provided first, instead of antidepressants, to older adults with mild to moderate depression as indicated by best practice guidelines?12 We would detect depression earlier and probably see fewer recurring episodes of depression as well as improvements in chronic conditions.

• Why isn’t delirium screening on patients in the intensive care unit (ICU) the norm? Approximately 80% of patients in the ICU are affected by delirium. Not performing the screening costs between $4 billion and $16 billion annually.13

These and many other examples of evidence-based practices will help shape a more sustainable and functional course for Medicare and provide better care for patients.

WHAT ARE THE BARRIERS TO IMPLEMENTING EVIDENCE-BASED PRACTICE?

Recent studies have shown that the adoption of evidence-based practices in hospitals and healthcare settings is lacking, even though leaders and executives believe in it. According to the Worldviews survey data of 276 chief nurse executives, more than 50% of the respondents said that evidence-based practices are utilized in their setting either “somewhat” or “not at all.”1 In addition, even more respondents reported that money wasn’t being allocated for resources to support the growth of an evidence-based practice culture in their healthcare environments, despite the fact that many hospitals are currently falling short of performance benchmarks for National Database of Nursing Quality Indicators measures.1

Lastly, the study illuminated a striking disconnect among nurse executives, most of whom say quality and safety are their top priorities, despite the fact that they may not be using evidence-based practices.1 In healthcare settings that may see a surge in the numbers of older adults, coupled with rising healthcare costs,14 barriers to implementing evidence-based practices must be addressed.

A good place to start is by improving the level of education of nurses and investing funds in continuing education programs and evidence-based practice mentors to equip them with the skills needed to consistently deliver evidence-based care. Studies show that baccalaureate-prepared nurses are more likely to espouse evidence-based practices and achieve better outcomes.15 Relatedly, hospitals with magnet recognition report better quality and workplace environments than nonmagnet hospitals.16 In order for healthcare systems to deliver the highest quality of care, they must devote a portion of their budgets to developing and sustaining a culture and environment that supports the delivery of evidence-based care by all nurses and other health professionals.

WHY SHOULD MEDICARE CARE ABOUT EVIDENCE-BASED PRACTICE?

A recent study by the Kaiser Family Foundation, citing US Census data, projects that the United States population over the age of 65 will nearly double between 2010 and 2050,6 and enrollment in Medicare will increase. The implications will be higher spending and a heftier burden on healthcare personnel and resources. According to National Health Expenditure pro-jections by CMS, increased enrollment from the baby boomer generation, increased utilization of care, and an improved economy will drive up payment rates, factoring into a yearly spending growth of 7.3%.14

The US Department of Health and Human Services, in partnership with the private sector, is looking to transition from volume-based, fee-for-service (FFS) payment models to models that are population-based and reward value. The following chart breaks down payment models across 4 different categories, with the goal of having 90% of Medicare FFS payments transition to value-based purchasing models (categories 2 through 4) by 2018 (see TABLE).17

According to CMS, the transition to value-based payment models will be accelerated if we “collaborate to generate evidence, share approaches, and remove barriers.” By making evidence-based practice a priority within their organizations and institutions, hospital executives can help expedite the shift from category 1 to category 4. In addition, it’s important that patients are empowered to ask the right questions about their care and demand that they are treated according to the soundest knowledge available.

Last year, Medicare reached the 50-year mark, and for it to remain viable for future generations, payment models need to be remedied and providers must evolve to create an environment that offers best practices for patients. To that end, it’s time all providers and patients add their voices to the evidence-based practice chorus. Bernadette Melnyk, PhD, RN, CPNP/PMHNP, FNAP, FAAN, is associate vice president for Health Promotion, chief wellness officer, and professor and dean of the College of Nursing at The Ohio State University. She also is a professor of pediatrics and psychiatry at the university’s College of Medicine. References

1. Melnyk BM, Gallagher-Ford L, Thomas BK, Troseth M, Wyngarden K, Szalach L. A study of chief nurse executives indicates low prioritization of evidence-based practice and shortcomings in hospital performance metrics across the United States. Worldviews Evid Based Nurs. 2016;13(1):6-14. doi: 10.1111/wvn.12133.

2. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2011.

3. Weiss AJ, Elixhauser A. Overview of hospital stays in the United States, 2012. Agency for Healthcare Quality and Research website. http://www.hcup-us.ahrq.gov/reports/statbriefs/ sb180-Hospitalizations-United-States-2012.pdf Published October 2014. Accessed April 7, 2016.

4. Kleinpell RM, Fletcher K, Jennings BM. Reducing functional decline in hospitalized elderly. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008.

5. Gillick MR, Serrell NA, Gillick LS. Adverse consequences of hospitalization in the elderly. Soc Sci Med. 1982;16(10):1033-1038.

6. Neuman T, Cubanski J, Huang J, Damico A. The rising cost of living longer: analysis of Medicare spending by age for beneficiaries of traditional Medicare. Kaiser Family Foundation website. http://kff.org/medicare/report/the-rising-cost-of-living-longer-analysis-of-medicare-spending-by-age-for-beneficiaries-in-traditional-medicare/. Published January 14, 2015. Accessed April 6, 2016.

7. Larme AC, Pugh JA. Evidence-based guidelines meet the real world: the case of diabetes care. Diabetes Care. 2001;24(10):1728-1733.

8. Magers TL. Using evidence-based practice to reduce catheter associated urinary tract infections. Am J Nurs. 2013; 113(6):34-42. doi:10.1097/01.NAJ.0000430923.07539.a7

9. Webster J, Osborne S, Rickard CM, New K. Clinically indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database Syst Rev. 2013;4:CD007798. doi: 10.1002/14651858.CD007798.pub3.

10. Yoder JC, Yuen TC, Churpek MM, Arora VM, Edelson DP. A prospective study of nighttime vital sign monitoring frequency and risk of clinical deterioration. JAMA Intern Med. 2013;179(16):1554-1555. doi:10.1001/jamainternmed.2013.7791.

11. Lyder CH, Ayello EA. Pressure ulcers: a patient safety issue. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008.

12. Final recommendation statement: depression in adults: screening. US Preventive Services Task Force website.

http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/depression-in-adults-screening1#Pod2. Published January 26, 2016. Accessed April 6, 2016.

13. Peitz GJ, Balas MC, Olsen KM, Pun BT, Ely EW. Top 10 myths regarding sedation and delirium in the ICU. Crit Care Med. 2013;41(9 suppl 1):S45-S56. doi:10.1097/ CCM.0b013e3182a168f5.

14. National Health Expenditure Projections 2014-2024. CMS website. https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/ nationalhealthaccountsprojected.html. Updated July 30, 2015. Accessed April 6, 2016.

15. Wilson M, Sleutel M, Newcomb P, et al. Empowering nurses with evidence-based practice environments: surveying Magnet, Pathway to Excellence, and non-magnet facilities in one healthcare system. Worldviews Evid Based Nurs. 2015;12(1):12-21. doi: 10.1111/wvn.12077.

16. Kutney-Lee A, Stimpel AW, Sloane DM, Cimiotti JP, Quinn LW, Aiken LH. Changes in patient and nurse outcomes associated with magnet hospital recognition. Med Care. 2015;53(3):550- 557. doi: 10.1097/MLR.0000000000000355.

17. Better care, smarter spending, healthier people: paying providers for value, not volume [press release]. Washington, DC: CMS Newsroom; January 26, 2015. https://www.cms.gov/ Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26-3.html.