Clinicians must turn evidence into practice

As the healthcare industry moves toward more quality initiatives, a greater emphasis has been placed on the role of evidence-based practices. It's a trend gaining momentum in both the medical and behavioral healthcare fields, and experts say treatment centers must be prepared.

"If they are not providing evidence-based or evidence-informed care, my suspicion is that in the next few years that will become very problematic for them," says Kelly Clark, MD, president-elect of the American Society of Addiction Medicine (ASAM).

Clark says as payers and regulators try to ensure that the care they are paying for and licensing is of high quality, they will be evaluating  whether facilities are embracing the latest evidence that has been shown to produce optimal patient outcomes. They want the most value for their healthcare dollar.

No easy task

While behavioral healthcare experts anticipate there will be a greater emphasis on evidence in the years ahead, they acknowledge that incorporating it is no easy process.  To truly develop treatment protocols and procedures based on the best clinical intelligence available, facilities will need to invest significantly in strategic training to translate what's discovered in a research setting into everyday practice.

Researchers and clinicians don't always see eye-to-eye. In fact, Melanie Smith, LMHC, program and training manager at the Renfrew Center in Coconut Creek, Fla., says there's a significant research-practice gap that exists that can often  prevent research findings from making their way into clinical practice. That lack of real-world application then can, in turn, prevent updated clinical observations from enhancing future research.

This gap exists in part because each stakeholder has a different motivation. While researchers value quantifiable, measurable data that be observed in structured research trials, clinicians often value subtle nuances of the treatment process and base decisions on what they can learn from other clinicians in real-world settings. While researchers examine statistical populations, clinicians examine individual human beings with unique needs.

But both groups can learn from one another, and experts say it will take a collaborative approach to help close the gap that exists between researchers and practicing clinicians.

"The hope is that researchers and clinicians can start a more collaborative relationship than has traditionally taken place," Smith says. "Researchers certainly have a strong viewpoint and set of opinions, and clinicians have an equally strong opposing view point and position about such things. An environment and an attitude of collaboration is going to be essential."

Anecdotal evidence

From a clinical perspective, evidence-based approaches can add value by giving clinicians a framework based on empirical data from many sources when treating patients. Smith says that while clinicians can work for years to provide the best care for their patients, they often draw much of their knowledge and experience from anecdotal evidence and what they see working with a small sample of patients in the short-term. 

"We don't really have a lot of ability to know in the long-term how our patients are doing, and we also don't have the ability to know, just based on our small experience in the world, whether or not what we're doing is the most effective and efficient way to help someone get better," she says.

She says one of the benefits of incorporating treatments and protocols based on research and literature is that it can help clinicians move toward using sound, scientific principles that can help improve overall clinician confidence.

"I always felt like I was throwing darts at a dart board and hoping that one of them stuck. I didn't necessarily have any information to give me any increased level of confidence that it was going to stick. We kind of just had to wait and see what happened," Smith says.

Over the last several years, as the Renfrew Center has taken a more evidence-based approach to care,  she's seen her confidence grow as a clinician.

"By no means does using an evidence-based treatment guarantee a patient will be cured in any sort of quick, expedient way. That's not what I am suggesting. I don't think that's what the researchers are suggesting either, but it certainly provides us more valuable information from a large sample of people over time, in all those variables, which as an individual clinician, you don't get to see day-to-day," she says.

Clark says evidence-based medicine—or what she says is more often “evidence-informed medicine”—lends itself to quality metrics that are population-based and allow clinicians and facilities to see an issue from a broader population-based perspective that provides bench marking opportunities.

Putting evidence into practice

Incorporating more evidence-based practices into treatment is often a decision made by organizational leadership. When top leadership makes a commitment to emphasize the evidence, Smith says, it helps  set the culture for the entire facility. Enlisting the help of the research community is another important step in the process.

At the Renfrew Center, Smith has spent the last few years helping to identify which research findings and evidence-based treatments the organization was going to adopt and incorporate into practice.

When the center launched the initiative, leaders formed a clinical excellence board that includes researchers in the field who serve as outside advisors to help provide objective feedback and ensure the facility is adopting policies that are consistent with current evidence. David Barlow, PhD, a professor at Boston University, and Kelly Clump, PhD, a professor at Michigan State University, have both published extensive research on the research gap and behavioral healthcare and serve on the clinical excellence board.

"We very explicitly handpicked two people who have been looking at this problem for a long time to help guide us because we recognized the gap. It’s a big problem in the field," Smith says.

Obviously, integrating new evidence-based approaches doesn't happen overnight. Smith says Renfrew spent several years working closely with researchers to translate the research in the field into something that can actually be delivered to its eight groups a day, seven days a week at the center's sites across the country.

"It took an intense amount of focus and energy and determination—and sacrifice, really—to be able to do that on the front end before we were even able to begin to implement it with actual people," she says.

For instance, the center has incorporated the use of exposure response prevention therapy procedures when treating patients with eating disorders, particularly those with anorexia, in the more advanced stages of their treatment model. The center uses the work of Joanna Steinglass, MD, from Columbia University, and colleagues, to guide their work and made minor modifications to the procedures to move it out of the laboratory and into practice.

The Renfew location in Florida was the first to pilot and implement some of the interventions. Now almost a year after implementation, Smith says it's been a positive experience for patients and staff. She says staff have reported feeling more enriched, supported and energized by learning something new and reinforcing the clinical modalities they already knew.

The Renfrew Center plans to implement the evidence protocol site by site through all 16 locations.

"Our goal here is to speak the same language: researchers and clinicians, to each other and amongst ourselves," Smith says. "We really want our patients to be speaking the same language as well. Having a grounding in specific evidence-based treatment allows us all to do that."

Finding the evidence

The search for evidence can be overwhelming, but there are several resources to help providers find relevant information on current research.

For instance, the National Institute of Mental Health can be a valuable resource for finding research specifically related to a clinician's field or subject of interest. SAMHSA funds the searchable National Registry of Evidence-based Programs and Practices (NREPP). The registry provides descriptive information and expert ratings for evidence-based programs submitted by researchers and intervention developers across the nation.

Smith says attending professional conferences is another way to hear about the latest findings in the field while also earning continuing education credits.

But evidence-based medicine often goes hand-in-hand with quality metrics so partnering with payers can be another strategy. Payers tend to have big data capabilities that can distill large volumes of claims data into actionable intelligence for clinicians.

"The plans can help facilities understand metrics the plans and the state would like to hold them to," Clark says. 

Lingering questions

Clark says that a lot of the evidence available today is often based on clinical trials that are required to bring a pharmaceutical or medical device to market. That can be problematic for the behavioral healthcare field because the studies may be limited by time constraints or restrictions from the FDA that might not represent real world scenarios. For instance, a trial on a depression medication might last eight weeks when the typical treatment for the illness may be longer.

Smith says while there is research available on behavioral healthcare issues, there's less information in the literature that defines the process for disseminating that evidence into practice.

"There's not a lot of information that's practical and usable for me in my office, so I think that training, implementation and dissemination research needs to grow and that will be helpful," she says.

Overall, Clark and Smith agree that in the years ahead the behavioral healthcare field will place a greater emphasis on evidence-based practices and facilities will need to find a way to bridge the gap between those studying best practices and those implementing them.

Jill Sederstrom is a freelance writer based in Kansas City