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Derek C. Angus

Physicians Are Familiar With Critical New Treatment Data But Fail To Use Them In The ICU

PITTSBURGH, November 19, 2002 — Though most critical care doctors are aware of new life-saving clinical trial results published in leading medical journals, many do not apply these results in their own intensive care units (ICUs), according to findings from an expert symposium held Nov. 5 at the 68th annual International Scientific Assembly of the American College of Chest Physicians (CHEST), in San Diego.

The findings were compiled by electronic survey of more than 200 attendees of “Best Critical Care Medicine: Are We or Are We Not Putting It Into Practice?” sponsored by the University of Pittsburgh School of Medicine .

“There is a potentially dangerous disconnect between the publication of solid, immediately usable data and putting those findings to work clinically,” said Derek C. Angus, M.D., M.P.H., FCCP, University of Pittsburgh School of Medicine, and chair of the symposium. “A fundamental tension exists between the desire to ‘first do no harm,’ and the need to incorporate new advances into practice. Doctors tend to be cautious about new advances until they are ‘proven.’ But failing to change practice on the basis of established, high-level evidence is essentially practicing out-of-date medicine.”

During the symposium, three speakers each reviewed a medical technique demonstrated to save lives in large clinical studies recently published in The New England Journal of Medicine. Each speaker discussed the results of the trials, as well as the available evidence regarding current practice patterns.

In addition, they polled the audience about their knowledge and practice regarding these techniques. Surprisingly, the audience reported using some of these therapies in less than 10 percent of indicated patients.

Reasons for this slow adoption included: the lack of proper education of medical staff; the reluctance of physicians to alter practicing habits; the failure of doctors to recognize acute lung infections, sepsis or other serious morbidities; physician apathy; cost and hospital financial constraints; too few incentives and penalties; the absence of quality assurance; and the lack of coordination between staff and departments (e.g., the emergency department and the ICU) that care for the critically ill.

“We already knew that slow adoption of new techniques was a problem,” said Dr. Angus. “After strong evidence was established for clot-busting therapy for heart attacks, for example, it was still many years before it was consistently provided. It is a great pity that we are likely re-learning the same problem with breakthroughs in the care of sepsis and acute lung injury. But the issues are complex and solutions are not straightforward.”

With the ICU as the place where one in five Americans currently dies, the need for guidelines to overcome these barriers to innovations in care is crucial.

Among the solutions proposed during the University of Pittsburgh School of Medicine’s symposium were: implementing institutional quality assurance programs to evaluate sepsis patients before they present to the ICU; instituting ongoing professional education efforts to help physicians keep current on medical advances for sepsis and other critical morbidities; and standardizing ICU and emergency department capabilities.

In addition, however, much time and discussion was focused on raising the awareness among doctors and other health care professionals of the need to become agents for change – to recognize the dangers of slow adoption of new evidence and take a leading role in trying to overcome resistance.

The symposium’s conclusions are in alignment with findings from a federal report released Oct. 30 by the National Academy of Sciences’ Institute of Medicine, which also stated grave concern over widespread failure to adhere to new standards of care based on high quality evidence. The report recommended that government provide financial incentives to hospitals and physicians who implement medical innovations to improve the quality of patient care. Such incentives, the Institute of Medicine maintains, will hasten the adoption of new medical technologies.

“The health care system is a very large and slow-moving industry. It has neither the top-down authority of a single-payer system, nor the economic incentives of a true competitive market. Effecting change, therefore, means finding creative ways to overcome a lot of inertia,” said Dr. Angus. “A system of incentives such as that announced by the Institute of Medicine can go a long way toward swiftly bringing life-saving therapies to the ICU. But such incentives will be hard to implement and will only be part of the solution. By constantly challenging ourselves to be leaders in bridging the chasm between new research and clinical practice, all of us in the medical profession will ultimately be the ones who make better care a reality for our patients.”

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