Clinical Medicine: Best Practices for Better Health

At its core, the Institute of Medicine (IOM) is dedicated to bringing the best minds together to analyze all of the possible knowledge on a given topic and present evidence-based, actionable recommendations to better the health of the nation. Thus it is easy to imagine that the way medical research is applied in clinical settings—how it impacts actual human lives—is a critical focal point for the IOM’s efforts.


Science has led to many great advances in the practice of medicine. However, all too often there is a disconnect between the best practices identified by research and the care that patients actually receive. The IOM informs clinical decision making by evaluating research in many different arenas and providing the best possible advice and knowledge directly to health care practitioners and consumers. The subjects of the IOM’s work include evidence-based medicine that is based on clinical practice, as well as evidence-based health care that responds to public health needs. Through these analyses, the IOM helps to reshape the way medicine is practiced in the real world for the benefit of the American people.

THE PROBLEM OF PRETERM BIRTH

In 2005, more than 12 percent of babies in the United States were born preterm after fewer than 37 wefis’ gestation. Although babies born before 32 wefis are at the greatest risk of dying, near-term or late-preterm babies—those born between 32 and 36 wefis—are at high risk for a host of health and developmental problems as well. There is great cost involved also: caring for preterm babies costs the U.S. health care system more than $26 billion annually. Despite great strides in improving the survival of preterm infants once they are in the hospital, too little is known about preventing these preterm births in the first place.


Preterm Birth: Causes, Consequences, and Prevention (2007) identified the troubling disparities that exist in preterm birth rates among different racial and ethnic groups. In 2003, nearly 18 percent of pregnant African American women gave birth to a preterm baby, compared with less than 12 percent of Caucasian, Asian, and Hispanic women. In addition, a host of socio-



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ClInICal MedICIne: Best PraCtICes for Better health Clinical Medicine: Best Practices for Better Health At its core, the Institute of Medicine (IOM) is dedicated to bringing the best minds together to analyze all of the possible knowledge on a given topic and present evidence-based, actionable recommendations to better the health of the nation. Thus it is easy to imagine that the way medical research is applied in clinical settings—how it impacts actual human lives—is a critical focal point for the IOM’s efforts. Science has led to many great advances in the practice of medicine. How- ever, all too often there is a disconnect between the best practices identified by research and the care that patients actually receive. The IOM informs clinical decision making by evaluating research in many different arenas and providing the best possible advice and knowledge directly to health care practitioners and consumers. The subjects of the IOM’s work include evidence-based medicine that is based on clinical practice, as well as evidence-based health care that responds to public health needs. Through these analyses, the IOM helps to reshape the way medicine is practiced in the real world for the benefit of the American people. the PRoBlem of PReteRm BiRth In 2005, more than 12 percent of babies in the United States were born pre- term after fewer than 37 weeks’ gestation. Although babies born before 32 weeks are at the greatest risk of dying, near-term or late-preterm babies—those born between 32 and 36 weeks—are at high risk for a host of health and developmental problems as well. There is great cost involved also: caring for preterm babies costs the U.S. health care system more than $26 billion annually. Despite great strides in improving the survival of preterm infants once they are in the hospital, too little is known about preventing these preterm births in the first place. Preterm Birth: Causes, Consequences, and Prevention (2007) identified the troubling disparities that exist in preterm birth rates among different racial and ethnic groups. In 2003, nearly 18 percent of pregnant African American women gave birth to a preterm baby, compared with less than 12 percent of Cauca- sian, Asian, and Hispanic women. In addition, a host of socio- 

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Informing the Future: Critical Issues in Health economic, biological, environmental, and other factors—often in combination— increase a woman’s risks of preterm delivery. Adolescents less than 16 years old are twice as likely as women over 18 to deliver preterm, and women 35 and older are at an increased risk as well. Maternal history is also a factor: if a woman has delivered preterm, she is more likely to do so in future pregnancies. The IOM committee recommended that federal agencies commit to sustained funding of research on the causes of preterm births. A multidisciplinary research agenda is needed to improve the prediction and prevention of preterm labor and to better understand the health and developmental problems that plague preterm infants. The report recommended that guidelines be issued to further reduce the number of multiple births resulting from infertility treatment, which is a significant risk factor for preterm birth. Release of the IOM report attracted nationwide media attention, including the major networks CBC, NBC, and ABC, as well as impacting legislation at the state and federal levels. The report’s recommendations led to the enactment of the PREEMIE Act, legislation designed to reduce preterm labor and delivery and the risk of pregnancy-related deaths and complications, as well as reduce infant mortality caused by prematurity. In the state of Indiana, legislation was intro- duced to expand and coordinate research on the prevention of preterm birth and the most effective care for preterm babies. SleePleSS in ameRica Between 50 million and 70 million Americans suffer from chronic sleep disorders such as insomnia, sleep apnea, and restless leg syndrome. Not only can a sleep disorder impinge on daily functioning and quality of life, it also adversely affects people’s health and longevity. The cumulative long-term effects of sleep loss and sleep disorders have been associated with a wide range of health consequences, including an increased risk of hypertension, diabetes, obesity, depression, heart attack, and stroke. Nearly 20 percent of all serious car crash injuries in the general population are associated with driver fatigue and sleepiness independent of alcohol effects. As a result of all the various effects of sleep disorders, hundreds of billions of dollars are spent every year on direct medical costs associated with doctor visits, hospital services, prescriptions, and over- the-counter medications. 

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Clinical Medicine: Best Practices for Better Health 11:00 p.m. 11:00 p.m. 7:00 a.m. Body temperature in relation to time of day. SOURCE: Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem, p. 44. The American Academy of Sleep Medicine, the National Center on Sleep this is a fixed image. Disorders Research at incrrease the National Sleep Foundation, and the Sleep If this the NIH, in contrast is not sufficient Research Society requested that the IOM conduct a study that would examine we will have to redraw the image the public health significance of sleep disorders and identify opportunities for improving and stimulating interdisciplinary research, education, and training in sleep medicine. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem (2006) concluded that a coordinated strategy is needed to continue clinical and scien- tific advances in sleep research. To lessen the public health and economic burden caused by nearly 0 percent of all serious car sleep loss and sleep disorders, the workforce crash injuries in the general population required to meet the clinical and scientific de- are associated with drier fatigue and mands in this field must be expanded. Health sleepiness independent of alcohol care workers as well as the general public must effects. be made aware of the serious nature of sleep loss and sleep disorders, and surveillance and 

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Informing the Future: Critical Issues in Health monitoring of the public health effects should be improved. In addition, more diagnostic and therapeutic technologies for identifying and treating sleep disor- ders are needed. The report received coverage in newspapers and other media outlets across the country, including a feature on CBS’s Early Show in a Healthwatch segment. The report’s recommendations led to the development of guidelines by the American Academy of Sleep Medicine to accredit academic sleep centers. life afteR canceR In the United States, half of all men and one-third of all women will develop cancer in their lifetimes. Advances in the detection and treatment of cancer, com- bined with an aging population, mean that “cancer survivor” will be a demo- graphic category of its own in the near future. Despite this increase, primary care physicians and other health care providers often are not familiar with the secondary consequences of cancer or cancer treatments and seldom receive ex- plicit guidance from oncologists. Furthermore, the lack of clear evidence of what constitutes best practices in caring for patients with a history of cancer contrib- utes to wide variations in care. The transition from active treatment of cancer to post-treatment care is es- sential to long-term health. In addition to being at risk for cancer recurrence and for developing other cancers, survivors may also . . . primary care physicians and face psychological distress, sexual dysfunction, other health care proiders often infertility, impaired organ function, cosmetic are not familiar with the secondary changes, and limitations in mobility, commu- consequences of cancer or cancer nication, and cognition. In part, this is a direct treatments and seldom receie explicit result of treatment: many cancer treatments— guidance from oncologists. including surgery, chemotherapy, hormone ther- apy, and radiation therapy—may have long-term effects on tissues and organ systems. If care is not planned and coordinated, survivors are left without knowledge of their heightened risks or appropriate follow-up plans for action. To make up for shortfalls in the care currently provided to the 10 million cancer survivors in the United States, the IOM report From Cancer Patient to Cancer Survivor: Lost in Transition (2006) recommended that each cancer patient receive a “survivorship care plan.” Such plans should summarize information critical to the individual’s long-term care, including a history of the cancer diagnosis, treatment, and potential consequences; the recommended timing and content 0

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Clinical Medicine: Best Practices for Better Health 12 10 Number (in millions) 8 6 4 2 0 70 72 74 76 78 80 82 84 86 88 90 92 94 96 98 00 02 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 20 20 Year Estimated number of cancer survivors in the United States from 1971 to 2002. SOURCE: From Can- cer Patient to Cancer Survivor: Lost in Transition, p. 25. 2-1 of follow-up visits; advice on maintaining a healthy lifestyle and preventing recurrent or new cancers; legal rights affecting em- ployment and insurance; and the availability of psychological and support services. Details of survivorship care plans were specifi- cally reviewed in a follow-up workshop Implementing Cancer Survi- vorship Care Planning: Workshop Summary (2007). Cancer survivorship should be recognized as a distinct phase of cancer care. Participants in the care planning workshop called for health care providers, patient advocates, and other stakehold- ers to raise awareness of the needs of cancer survivors. For ex- ample, leadership organizations for physicians, nurses, and other health care providers should collaborate to improve care, and in- surance companies should improve access to necessary services through more generous reimbursement policies. Policies should be enacted to improve cancer survivors’ quality of life, such as ensuring access to psychosocial services, fair employment practices, and health insurance. 

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Informing the Future: Critical Issues in Health To ensure that the 2006 report’s message was widely disseminated, a FREDDIE award–winning video was produced to accompany it. After the report’s release, Congress introduced the Comprehensive Cancer Care Improvement Act of 2007 (H.R. 1078) to implement its recommendations. The bill provides for coverage of comprehensive care planning under the Medicare program and would improve the care furnished to individuals diagnosed with cancer by establishing a Medicare hospice care demonstration program and grants programs for cancer palliative care and symptom management, provider education, and related research. mental oR SUBStance-USe PRoBlemS: qUality of caRe Each year more than 33 million Americans receive health care for mental or substance-use problems and illnesses. The diagnoses and severity of mental and substance-use problems vary widely—from distress caused by a life-changing event to severe depression to physical dependence on alcohol. These conditions are the leading cause of combined disability and death in women, and the second highest in men. Effective treatments do exist for many of these problems, and they continually improve. However, as with general health care, deficiencies in the way these treatments are delivered prevent many from receiving appropriate care. This has seri- ous consequences for people who have the conditions; for their loved ones; for the workplace; for the education, wel- fare, and justice systems; and for the nation as a whole. The IOM report Crossing the Quality Chasm: A New Health System for the 21st Century (2001) set forth a strategy for im- proving health care in general. The report described quality issues and defined six aims—care should be safe, effective, patient-centered, timely, efficient, and equitable—and ten rules for care delivery redesign. Health care for mental and substance-use conditions has a number of distinctive characteristics, however—including the greater use of coercion into treatment, separate care delivery systems, a less developed infrastructure for measuring the quality of care, and a differently structured marketplace. These and other differences have raised questions about whether the same quality mea- surement and remediation approach are applicable to health care for mental and substance-use conditions. 

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Clinical Medicine: Best Practices for Better Health Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series (2006) built on previous reports by laying out a multifaceted strategy for incorporating the recommended general health framework into men- tal and substance-use health care. The strategy addresses the essential role that health care plays for mental and substance abuse health care for mental and substance- conditions in improving overall health. To that use conditions has a number of end, the report identified actions that should distinctie characteristics, howeer— be required of clinicians, health care organiza- including the greater use of coercion tions, health plans, purchasers, all levels of gov- into treatment, separate care deliery ernment, and all other parties involved in health systems, a less deeloped infrastructure care for mental and substance-use conditions. for measuring the quality of care, and a differently structured marketplace. The IOM received a forWARDS™ award in 2006 from the National Mental Health Association (NMHA) for its latest Quality Chasm report. The NMHA developed the program to pay tribute to the people, ac- tions, and events that advance the cause of mental health each year. Additionally, the Johns Hopkins Bloomberg School of Public Health offered a class during the summer of 2006, “The IOM Blueprint for Improving Mental Health and Substance Use,” based on the Quality Chasm report. evidence-BaSed medicine The IOM is founded on the principle of using sound scientific evidence to drive policy and research. The health of Americans has greatly benefited from the rapid growth of medical research and technology over the years, but multiple studies have shown that too few of the medical services supported by the stron- gest evidence are actually delivered and that far too much health care spending is devoted this gap in knowledge will continue to activities that do not improve health. In fact, to increase as the pace of technology little time or money has been invested in under- deelopment quickens and the standing the advantages of different interven- benefits of genetic research and other tions. This gap in knowledge will continue to reolutionary areas of inquiry eole increase as the pace of technology development into therapies and medications. quickens and the benefits of genetic research and other revolutionary areas of inquiry evolve into therapies and medications. Bridging this divide is fundamentally important to the efforts to improve the ef- ficiency and efficacy of health care in America. To address these issues, the IOM convened the Roundtable on Evidence- Based Medicine. The roundtable brings together key stakeholders from multiple sectors—healthcare providers, patients, insurers, employers, manufacturers, 

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Informing the Future: Critical Issues in Health policy makers, and researchers—for cooperative discussions and consideration of the ways in which evidence can be better developed and applied to improve the effectiveness of medical care. Thus far, participants have discussed efforts to move toward a “learning” healthcare system, in which evidence is applied and developed as a natural product of patient care. Another focus has been on advancing the capacity to generate clinical evidence for medical care that is most effective and provides the greatest value. Participants are also examining how to improve public understanding of evidence and its dynamic nature. This work is critically important to the IOM’s mission of providing well-founded advice to the public, including medical practitioners.