Evidence-Based Medicine Comes to Otolaryngology

Not long ago, physicians routinely decried evidence-based medicine (EBM) as an encroachment on their professional autonomy, a barrier to good patient care, insensitive to health care’s growing complexity, and at odds with the transcendent value of the physician-patient relationship. Those objections have been swept away by the 21st century’s tidal wave of health care change-the quality improvement movement, pay-for-performance initiatives, and adoption of information technology. The 109th Congress’ last-minute passage of legislation that boosts reimbursement to physicians who report data on the quality of care they deliver is a huge step to tying EBM to reimbursement. Legislators may take further steps. They are using guidelines to pinpoint and, eventually, eliminate regional variations in medical treatments; to reduce spending on expensive ineffective therapies; and to encourage physicians to use evidence-based low-cost treatments rather than high-tech ones without mountains of EBM behind them. In short, EBM isn’t going away.

Evidence-based medicine-the conscientious, explicit, and judicious use of current best data in making decisions about patient care-is here to stay. Payers are determined to align financial rewards to better clinical outcomes, which are defined through evidence-based guidelines. It sounds simple; it isn’t.

Most medical specialties, including otolaryngology, lag behind internal medicine in developing evidence-based medical guidelines. It isn’t because EBM is less important to specialties than to primary care medicine, only that each specialty consumes less of the health care spending pie than do primary medicine’s diagnoses. Understandably, public and private payers have pursued the most commonly diagnosed conditions that consume, in the aggregate, a proportionally larger amount of available resources-the low-hanging fruit.

By that logic, the key areas chosen by the Centers for Medicaid and Medicare Services (CMS) for pay-for-performance measures based on EBM account for 33% of hospital admissions and 20% of total claims paid. Those core measures, on which hospitals can now earn an additional 5% Medicare reimbursement for top-tier performance, relate to coronary artery bypass graft, acute myocardial infarction, community-acquired pneumonia, and heart failure. Conversely, hospitals performing poorly on the core measures lose 5% of Medicare payment.

A Different Perch

Medical specialties see EBM from a different vantage point than primary care physicians, who already have some pay tied to performance. With few payer incentives (yet) to develop guidelines, perhaps specialists have been hoping that the health care system’s focus on EBM would wane and pass them by, unscathed. Not so, according to David Nielsen, MD, CEO of the American Academy of Otolaryngology-Head and Neck Surgery Foundation. He said, We really can’t make excuses about not developing our own EBM. Because of the Cochrane Collaboration [see box] and other groups that focus on quality measures in medicine, we knew this was coming. We wrote consensus-based guidelines and that satisfied most practitioners, but it’s time for evidence-based medicine in our specialty.