Evidence-based practice is an important step in the current health care evolution. Model guided practice change provides clinical effectiveness with the best available research information, which affect positive patient outcomes. “EBP is a problem-solving approach to clinical decision making that integrates the best evidence from well-designed studies with a clinician`s expertise along with the patient`s preference and values “ (Melnyk et al. 2012). This paper will discuss the utilization of the Iowa Model to promote hyperlipidemia treatment in an outpatient clinical setting. The Evidence that constitutes for Evidence Based Practice
Polit & Beck (2008) is defining the evidence-based practice as the conscientious use of current best evidence in making clinical decisions about patient care. Because EBP is constantly evolving, it is not enough to learn best practice once and for all. Rather, practitioners need to be prepared to learn on a lifelong basis. Evidence-based practice demands changes in education of students, more practice-relevant research, and closer working relationships between clinicians and researchers. The evidence-based practice also provides opportunities for nursing care to be more individualized, more effective and streamlined.
One of the advantages of EBP is that it takes away from the traditional method of decision-making and focuses on the best research evidence. EBP does not diminish the importance of clinical decision-making skills but requires that such decisions be based on both the clinical situation as well as the best-identified practice (Polit & Beck, 2008). The effect of evidence-based practice is standardizing health care practices using science and the best evidence available. The Institute of Medicine calls the “quality chasm” – the gap between what is known to be the best health care, and what is actually practiced. Institute of Medicine, 2002).
To learn the most and to develop greater expertise, we must carry this life lessons from prior experience that demonstrate evidence-based practice. Overview of The Iowa Model of Evidence Based Practice The Iowa Model of Research-Based Practice to Promote Quality Care (Fig. 1), developed at the University of Iowa Hospitals and Clinics in 1994 (Titler et al. , 2001). The Iowa Model has several components to provide an organized approach to implementing research into practice, by focusing on key triggers that can be either problem focused or knowledge focused.
There are seven steps to follow in this model: (1) Selection of a topic, (2) Forming a team, (3) Evidence retrieval, (4) Grading the evidence, (5) Developing an EBP standard, (6) Implement the EBP, (7) Evaluation. The first step of the Iowa Model reflects on the magnitude of the problem, where the topic is formulated into a PICOT question. Posing the right question, using the PICOT format is critical, in order to begin an evidence-based inquiry. Based on the formulated PICOT question, analyzing and synthesizing literature will help individual studies to support the clinical relevance Kitson, 2000).
The second step is to determine if there is a relevance to the organization, is there a priority of the problem exist, and is there any evidence to answer the formulated clinical question. The process of changing the existing workflow requires collaboration from staff members and a team is necessary to be formed in order to examine, support, and implement clinically relevant findings. Evidence retrieval and grading evidence are crucial third and fourth steps, as they support the practicality of guideline implementation and its appropriateness to the urrent practice.
The type and strength of literature findings should support evidence-based practice and it is necessary to translate into the individualized organizational standards. During the database search, it is highly recommended to review The National Guidelines Clearing House database, as it provides information on guidelines that have already been established. Once the evidence has been gathered, evaluated and synthesized, the team should determine if there is enough evidence to support a practice change. Devised clinical guidelines should be carefully xamined by the team for feasibility, appropriateness, and effectiveness for the practice (Pearson et al, 2007).
Clinical Problem Cardiovascular disease remains the leading cause of death in the United States, however, provider adherence to 2013 American College of Cardiology/American Heart Association (ACC/AHA) treatment guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults remains a challenge. The treatment of hyperlipidemia is central when aiming for a long-term reduction of cardiovascular disease associated illnesses.
Lowering lipoprotein cholesterol (LDL-C) has been shown marked reduction with mortality rates in several studies, yet the current management of hyperlipidemia remains inadequate and controversial. The leading risk factors contributing to the prevalence and severity of coronary heart disease are primarily related to hyperlipidemia. Initial elevation of lipoprotein cholesterol mainly discovered during the annual physical exam in a primary care setting. As part of the evaluation for cardiovascular disease risk, blood pressure measurement, waist size, body mass index, fasting lipid and glucose level measurement should be included.
Obtaining comprehensive history to determine tobacco and alcohol use, as well as physical activity and dietary intake are also substantial information. When the relationship between the clinical problem and the population examined, there are multiple factors identified that needs immediate attention. Lifestyle modifications are the most achievable modifiable factors, however, patient adherence and comprehensive educational involvement requires ongoing collaboration (Koelewijn-van Loon, et al. 2008).
Patient`s capability to understand their indisputable cardiovascular risk can be increased by clarifying their own values, assessing individual needs and motivation factors by communicating in a patient-oriented way. Adherence can be greatly influenced by health beliefs, available information of treatment options and manageable approaches, tailored to each patient individually. Most patients prefer lifestyle change over drug treatment, however, detailed explanation is necessary if their preferences are unrealistic or does not serve their optimal health outcome. Koelewijn-van Loon, et al. 2008).
Utilization of The Iowa Model The current management of hyperlipidemia remains inadequate and controversial in primary care, despite the already established 2013 American College of Cardiology/American Heart Association (ACC/AHA) treatment guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults. At my current workplace as a primary care provider, I face this critical issue on an everyday basis and I feel that there is a major gap in practice management and adherence to hyperlipidemia treatment.
Utilization of the Iowa Model helped me identify this problem-focused trigger and the generation of the PICOT question magnified the significance of this practice concern. The PICOT question focuses on this clinical issue and by researching the literature, it was evident that there is enough evidence to support a practice change. The PICOT question focuses on the importance of the outcome if practice guidelines are not followed: In the adult population, how does cholesterol treatment guideline adherence versus inconstancy affect atherosclerotic cardiovascular disease risk over 10-years?
Currently, there is no established practice policy or process exists in order to enforce the providers to implement the ACC/AHA guideline. In order to be compliant and implement the established recommendations for cardiovascular disease prevention, an organized, unified, and effective method needs to be implemented. Healthcare information technology became an essential tool with its numerous possibility to assist, improve and enhance patient outcome.
According to Blumenthal & Tavenner (2010), “HIT is expected to enhance the quality of care, increase healthcare safety, and provide cost- effective health services for patients by facilitating evidence-based medicine which, in turn, is expected to improve care delivery”. Access to clinical guidelines, patient information exchange and data accessibility are already exist, however, it is not universally accepted and utilized. Aggregated data, feedback for clinical measures with incorporated guideline recommendations should further improve guideline adherence.
The capacity to follow patient outcome either at the home settings or among providers would allow clinicians to evaluate treatment effectiveness as well as monitor measure outcomes. Advanced computer technology is capable of creating a statistical analysis of patient information, which data could provide essential feedback on any guideline adherence with numerical values. Tracking patient outcome could also serve as an evidence-based resource, which could supply objective data for further research. Translating the Iowa Model concept to my current practice, by following its seven-step process can be piloted as follows:
(1) Selection of a topic (PICOT question) – In the adult population, how does cholesterol treatment guideline adherence versus inconstancy affect atherosclerotic cardiovascular disease risk over 10-years? (2) Forming a team – Practitioner guided group of professionals, including the office manager
for financial applicability.
(3) Evidence retrieval – Electronic database retrieval using the National Guidelines Clearing
House, Cinahl, Medline, Cochrane, NICE, and QHP databases
(4) Grading the evidence – During weekly meetings, findings can be summarized and analyzed
for practice appropriateness, deliverability, and practicality.
(5) Developing an EBP standard- To support evidence-based practice, the design should be based
on patient population and complexity of diseases considering the feasibility of the practice.
(6) Implement the EBP – Incorporating our Allscripts electronic health record system, implementation of guideline recommendation based on EBP, will aide the providers to access the ACC/AHA guideline,