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Using the evidence-based medicine and evidence-based management to minimise overuse and maximise quality in healthcare: a hybrid perspective
  1. Edris Hasanpoor1,
  2. Ali Janati2,
  3. Morteza Arab-Zozani2,
  4. Elaheh Haghgoshayie1,2
  1. 1 Department of Healthcare Management, Maragheh University of Medical Sciences, Maragheh, Iran
  2. 2 Department of Health Services Management, Iranian Center of Excellence in Health Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
  1. Correspondence to Dr Elaheh Haghgoshayie, Department of Healthcare Management, School of Nursing and Midwifery, Maragheh University of Medical Sciences, Maragheh, Iran; ezd_ehm2010{at}yahoo.com

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Introduction

The main preference is addressing the expenditure of healthcare, which increases in the majority of developed countries. Overuse and unessential healthcare are one of the most amazing areas to aim is described as services that provide small or no advantage to patients or healthcare centres. Today, if physicians routinely provided medical services consistent with the latest scientific evidence, all patients could obtain more benefit from implementing clinical guidelines. Therefore, two parts are essential to progress the quality of healthcare: improvement of evidence-based medicine (EBMed), which reinforces the clinicians’ skills and identifies the clinical actions leading to better medical services, and evidence-based management (EBMgt), which recognises the hospital strategies, organisation, and management practices to provide evidence-based medical services. An evidence-based approach has been promoted as a systematic mechanism of the best available evidence to management and medicine decision-making process, addressed at improving the performance of health services organisations.1–4

High expenditure on medical care costs without cost-effectiveness considerations may cause absolutely loss. Many factors involve overusing, including technology development, providers’ payment mechanisms that increase utilisation of medical care, creeping, patients’ values and legal considerations of patients.5–7 Overuse in medical care can be categorised into three main parts: overuse of testing, which can lead to overdiagnosis of disease. Overuse of testing causes false-positive results and over diagnosis; overtreatment, which includes providing treatment; and treatment of overdiagnosed disease.8 Negative test findings do not appear to genuinely reassure patients. Both physicians and patients are responsible for exceeding overuse of healthcare, and both sections are experiencing the outcomes. This joint responsibility between physician and patient may translate into improved patient satisfaction and patient care. In overtreatment, patients were placed at a risk of adverse events with increasing both medical treatments and systemic interventions.9 10

The results of an analysis showed that $700 billion is wasted annually in the US healthcare system, overtreatment or the delivery of healthcare services for which the risks overpass the benefits has been recognised as a significant part, equalling approximately $280 billion (40%). Interest in overuse has begun to achieve traction, particularly by physician managers. Several national clinician teams have undertaken the overuse of screening and testing of diagnostic, identifying many strong strategies in medical services that have low value and high expenditure for a healthcare system. The findings of different studies indicated that overuse is happening among numerous clinicians and overuse of medical care is rapidly maximising.6 8 9 11–13

This perspective suggests that the EBMed and EBMgt represent the critical methodologies to target overuse, both for data collection and as a medium for direct intervention. There are intrinsic advantages of EBMed and EBMgt as an agent for change, including its ability to be used flexibly and in lean solutions.1–3 14

EBMed and EBMgt: two models for minimising overuse and maximising quality

As previously mentioned, improvement of  EBMed and EBMgt are two components to minimise overuse of medical care and to maximise the quality of healthcare. Improvement in EBMed, which identifies the physician’s practices, leads to better care using the guideline of providing healthcare and awareness of how to translate this knowledge into clinical practice. In addition, advances in EBMgt identify the management strategies, infrastructures and human resources management practices that enable clinicians and other health specialists to provide evidence-informed healthcare.1–3 14 Therefore, a combination of knowledge and performance EBMed and EBMgt can help to ensure the overuse minimisation of medical care. On the other hand, EBMgt, an evolving concept, originally taken from EBMed, started in the late 1990s. For that reason, these two models are heavily interdependent.1 2 15

The EBMgt can support by using awareness from engineering of human factors inside high-reliability organisations that exist in such hazardous environments where the outcomes of errors are high, but the occurrence of an error is very low, on changing managerial and organisational culture, and on developing high applying groups. The EBMgt improves organisational and managerial decisions as a bridge from theory to practice, and it has a critical impact on organisation performance. Also, EBMgt can contribute to developing the use of recommended healthcare processes by providing knowledge about organisational capacities. For example, existing research examining the influences of financial rewards to physician practices for meeting quality standards (pay for quality or pay-for-performance schemes) has found mixed impacts.1

The interaction between EBMed and EBMgt illustrates an important element for developing the country’s healthcare system. Due to the increased demand for better and measurably valuable care, combined with increasing expenditure and quality forces for healthcare evolution, the following proposed framework may be useful for improving the integration of EBMed and EBMgt and for reducing the obstacles to applying the decision-making process.

Proposed framework for minimising overuse and maximising quality

The hybrid framework of EBMed–EBMgt for minimising overuse can be considered as a good tool for better decision-making for healthcare managers and physicians in minimising overuse. Healthcare managers require to more often advising research results for decision-making, including both qualitative and quantitative evidence in healthcare administration, in addition to professional skill, political–social development plans, ethical–moral evidence, fact and information of hospital, and stakeholders’ values and expectations. On the other hand, physicians need to follow the pyramid of evidence based on evidence-based decision-making (EBDM). Therefore, a linkage between EBMed and EBMgt leads to minimise overuse.

Our framework helps healthcare managers and physicians to pursue the multiple evidence sources in process of knowledge utilisation. By using hexagon of evidence sources and pyramid of evidence, healthcare managers and physicians can determine the best available evidence for management and clinical decisions in an EBDM process to make the best decisions. Hexagon of evidence and pyramid of evidence are the best sources of evidence in management and medicine, respectively. Categorising the pyramid of evidence is based on the quality of studies. To adopt and apply EBMgt, healthcare managers and physicians need to develop a culture that helps administrators to dedicate time to consult scientific-research evidence; personnel in academic and research institutions need to focus on improving EBMgt skills that are needed to discover, read, evaluate and apply scientific research evidence. Universities and research centres’ managers need to design the development plan for academics to train framework about methods needed to critically appraise and summarise the best available evidence for achieving the best practice for best performance.

As shown in figure 1, we identified the sources of evidence in EBMgt and EBMed. Depending on the problem, using the EBDM process, healthcare managers (downward) and physicians (upward) will pick out the best available evidence and sources. A full evidence-based person is a person who utilises all sources of evidence in the decision-making process with fundamental six steps (figure 1). Healthcare managers and physicians should apply the best evidence based on the problem or population. In the first phase (asking), practical issue or problem translate into an answerable question. Acquiring is the second phase and it is a systematically searched for finding the evidence. In the third phase, correctness and appropriateness of the evidence will be appraised critically. Then, will be weighed and pulled evidence and in the fifth phase, evidence will be applied in organisational and clinical decisions. Finally, an outcome of the decision taken will be assessed. These six phases were named 6A (asking, acquiring, appraising, aggregating, applying and assessing).

Figure 1

Hybrid framework of EBMed–EBMgt for minimising overuse. EBMed, evidence-based medicine; EBMgt, evidence-based management; EBDM, evidence-based decision-making.  

Conclusion

EBMed and EBMgt can improve quality of decisions and consequently promote delivery of medical care, effectiveness and efficiency. Healthcare managers and clinicians can create a conducive environment and provide socialising opportunities to promote peer-to-peer information and knowledge sharing together. The education of all healthcare managers and physicians is a great need for improving the application of EBMed and EBMgt. For both EBMed and EBMgt, substantial problems would include assessment of what establishes reliable and applicable evidence, how to conduct qualitative and qualitative systematic reviews, and how to use the sources of evidence in clinical and managerial practice. Training programmes can be useful to develop audit teams in order to adhere to the list of commitments. Legal and policy requirements and cost-effectiveness interventions are required for both models. The content of EBMed and the context of EBMgt will be led to provide better healthcare services for all patients. The lack of communication between clinicians and healthcare managers is one of the main obstacles to using EBMed and EBMgt. Therefore, an interaction between the two groups of decision-makers is an influential means by which to generate practice-relevant knowledge and enable evidence-informed practice. Integration of evidence-based approach in medicine and management can reduce the overuse and improve quality of healthcare in health services organisations.

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Footnotes

  • Contributors All the authors contributed to the first draft of the paper, revised it for critical reasonable content and reviewed the final draft.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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