1. Beyond Journal Club: Transforming Evidenced Based Practice and Teaching in a Residency Patient-Centered Medical Home

2. W. Suzanne Eidson-Ton, MD, MS W. Suzanne Eidson-Ton, MD, MS Thomas Balsbaugh, MD Thomas Balsbaugh, MD Shelly Henderson, PhD Shelly Henderson, PhD University of CA, Davis University of CA, Davis Department of Family and Community Medicine Department of Family and Community Medicine

3. We have no financial disclosures. We have no financial disclosures.

4. Outline Discuss Evidence-Based Practice in the Patient Centered Medical Home Discuss Evidence-Based Practice in the Patient Centered Medical Home Discuss our attempts to improve our own use of evidence in our residency PCMH Discuss our attempts to improve our own use of evidence in our residency PCMH Discuss your strategies for this and whether “FRED” could help you Discuss your strategies for this and whether “FRED” could help you

5. The Problem Residency Teaching Clinic Residency Teaching Clinic Patient Centered Medical Home Patient Centered Medical Home Use of Guidelines Use of Guidelines Journal Club Journal Club Variation in practice and precepting styles Variation in practice and precepting styles Reference: Tricoci, P, et al. “Scientific Evidence Underlying the ACC/ AHA Clinical Practice Guidelines.” JAMA. 2009;301(8): 831-841

6. Definition Evidence-Based Practice Evidence-Based Practice Evidence-based practice (EBP) or evidence-based medicine (EBM) is an approach to health care practice that explicitly acknowledges the evidence that bears on each patient management decision, the strength of that evidence, the benefits and risk of alternative management strategies, and the role of patients' values and preferences in considering the benefits and risks. Evidence-based practice (EBP) or evidence-based medicine (EBM) is an approach to health care practice that explicitly acknowledges the evidence that bears on each patient management decision, the strength of that evidence, the benefits and risk of alternative management strategies, and the role of patients' values and preferences in considering the benefits and risks.

7. EBM in the Medical Home National Committee for Quality Assurance National Committee for Quality Assurance “Evidenced-Based” Clinical Guidelines “Evidenced-Based” Clinical Guidelines Performance Based Payments Performance Based Payments

8. FRED: Faculty/ Resident Evidence Discussion Precepting principles Group practice culture Clinical practice change Medical Evidence Review Methodological Quality / Study validity Individual Practices / Beliefs Individual Patient care Journal Club FRED

9. Tools for FRED Human Resources Human Resources EBM Experts EBM Experts Content Experts Content Experts Research Faculty Research Faculty Residents Residents Data Generation Data Generation EHR (we use Epic) EHR (we use Epic) Report Writer Report Writer AA support AA support

10. MedStaff Curriculum Committee Faculty Clinic Precepting Article ID (At least 2 people) CQICSICurriculumHRSA Faculty Meeting Med Staff Meeting Clinical Question Generation FRED Journal Club -Clinical & Teaching Conclusions -Practice Improvement Strategies

11. FRED 1 Question: Should Aspirin be Routinely Prescribed for all Patients with Diabetes? Question: Should Aspirin be Routinely Prescribed for all Patients with Diabetes? Practice Data: 350/ 1054 patients with DM had been prescribed ASA over 2 years. Practice Data: 350/ 1054 patients with DM had been prescribed ASA over 2 years. Bottom Line: ASA should be prescribed for other indications (use cardiovascular risk calculators), and does not need to be given for DM alone. Bottom Line: ASA should be prescribed for other indications (use cardiovascular risk calculators), and does not need to be given for DM alone.

12. FRED 2 Question: Who should get routine screening mammograms? Question: Who should get routine screening mammograms? (We did this before the new USPSTF Guidelines were released.) (We did this before the new USPSTF Guidelines were released.)

13. FRED 2: Practice Data

14. FRED 2 Bottom Line Definitely screen women over 50 with mammograms, stop at a reasonable time given the health of each individual woman. Screen women 40-50 after discussion of risks/benefits. Definitely screen women over 50 with mammograms, stop at a reasonable time given the health of each individual woman. Screen women 40-50 after discussion of risks/benefits. Our practice: We do OK, but could improve. Our practice: We do OK, but could improve.

15. FRED 3 Question: Who should be screened and subsequently treated for osteoporosis in our clinic? Question: Who should be screened and subsequently treated for osteoporosis in our clinic?

16. Fred 3: Practice Data 2611 Women over 50 years of age were seen in the past 2 years 1327 were aged 50-59 46% had a DEXA scan 12% were diagnosed with osteoporosis 14% of them were treated with bone mineral reuptake inhibitors 8% were diagnosed with osteopenia 905 were 65 yo and older 70% had a DEXA scan 38% were diagnosed with osteoporosis 41% of them were treated with bone mineral reuptake inhibitors 12% were diagnosed with osteopenia

17. FRED 3 Bottom Line Screen women over age 65 or with RFs, treat ONLY osteoporosis. Consider using FRAX (a risk calculator). Screen women over age 65 or with RFs, treat ONLY osteoporosis. Consider using FRAX (a risk calculator). Our practice: We over-screen young women and over-treat all. Our practice: We over-screen young women and over-treat all.

19. Outcomes of FRED Broader faculty involvement in resident teaching regarding EBM Broader faculty involvement in resident teaching regarding EBM Thoughtful exchange between faculty regarding precepting principles and practice guidelines Thoughtful exchange between faculty regarding precepting principles and practice guidelines Careful consideration of our own practice data regarding issues we care about Careful consideration of our own practice data regarding issues we care about Demonstration of use of EBM in the “real world” Demonstration of use of EBM in the “real world”

20. What Are Others Doing? How do you implement practice guidelines? How do you conduct “Journal Club?”

21. Discussion How do you manage differences in approaches to guidelines? How do you manage differences in approaches to guidelines? How do you use practice data for practice improvement and resident education? How do you use practice data for practice improvement and resident education? What questions or topics would you explore via this method? What questions or topics would you explore via this method?