# Presentation: 337904

## Clinical Guidelines:  Building Blocks for Effective Chronic Illness Care

- Jean Slutsky, P.A., M.S.P.H.
- Director, National Guideline Clearinghouse
- Project Director, US Preventive Services Task Force
- U.S. Agency for Healthcare Research and Quality

**Notes:**
“Slutsky intro”

## Finding the Evidence

- Approximately 8,000 completed references are added to MEDLINE each week (over 400,000 added per year)
- Too much for any one person to evaluate
- Uncertainty results in:
- variations in care
- under and over utilization of services

**Notes:**
“evidence”

## Putting Evidence into Practice

- 	It may take as long as 17 years for original research to be put into routine clinical practice
-       Source: Balas EA, Boren SA. Managing Clinical Knowledge for Health Care Improvement. Yearbook of Medical Informatics. Schattauer, 2000: 65-70.

**Notes:**
“Evidence-practice”

## Documented Variation in Treatment of Congestive Heart Failure

- Source:  *Effective Clinical Practice*, March/April 2000

**69 hospitals in 5 states;**
**2077 patients with CHF**

**Notes:**
“variation”

## Under-use of Beta-blockers

- Despite strong evidence that use of beta-blockers following acute myocardial infarction (AMI) decreases morbidity and mortality, they are substantially under used in the elderly.
- Beta-blocker prophylaxis after AMI is one of the most scientifically substantiated, cost-effective medical services. Their use decreases cardio-vascular mortality and reinfarctions, and increases survival by 20% to 40%.
- Under use leads to excess 2-year mortality and re-hospitalization for cardiovascular disease.

- Source: JAMA January 8, 1997; 277: 115-121

**Notes:**
“beta-blockers”

## Under-use of Beta-blockers (cont’d)

- Only 21% of eligible New Jersey Medicare beneficiaries received beta-blocker therapy following their heart attack.
- Calcium channel blockers were used almost 3 times as often despite a lack of evidence that they decreased mortality.
- Patients on beta-blockers were re-hospitalized 22% less often and their mortality rate was 43% lower than non-recipients.
- Patients receiving calcium channel blockers instead of beta-blockers doubled their risk of death
- 	 Source: JAMA January 8, 1997; 277: 115-121

**Notes:**
“under-beta”

## Examples of Quality of Chronic Health Care

- 52% of elderly adults received a flu shot in 1993
- 33% of hospitalized elderly discharged on an anti-depressant were on a dose below recommended level
- 49% of diabetic adults had dilated eye exam in past year
- 43% of patients who should have received coronary angiography received it within 3 months

- Source:  M.A. Schuster et al., *Milbank Q,* 1998; 76:517-563

**Notes:**
“examples”

## Chronic Care Management

- Do the *RIGHT* thing to the *RIGHT* patient at the *RIGHT* time.

**Notes:**
“CCMgmnt”

## Guidelines Can Improve Clinical Decisions

-     Clinical guidelines based on critical appraisal of scientific evidence (evidence-based guidelines) clarify which interventions are of proven benefit and document quality of supporting data.
- Alert clinicians to interventions unsupported by good science
- Reinforce the importance and methods of critical appraisal
- Call attention to ineffective, dangerous, and wasteful practices
- Source: *BMJ* 1999;318:527-530 ( 20 February )

**Notes:**
“guidelines”

## Slide 10

**Notes:**
“NGCweb1”

## Slide 11

**Notes:**
“NGCWeb2”

## Slide 12

**Notes:**
“NGCWeb3”

## Slide 13

**Notes:**
“NGCWeb4”

## In Summary

- Chronic illness care should be based on the best available evidence
- “Stop, look, and listen” and make sure that you know what you are using: who developed it, how good is the information, and is it current
- _[www.guideline.gov](http://www.guideline.gov/)__ provides access to evidence-based guidelines_

**Notes:**
“Summary”