SON Professor Measures Clinical Practice Improvement

The results of randomized controlled trials are always in the news these days, but not all research results come along that path. Dr. Susan Horn, research professor at The University of Texas-Houston Health Science Center, is one who firmly believes that there are other ways to improve healthcare practice.

Her two-part seminar - Clinical Practice Improvement (CPI): An Interdisciplinary Approach to Improving Practice - will be offered through the School of Nursing in October and November.

Dr. Horn, also senior scientist at The Institute for Clinical Outcomes Research in Salt Lake City, says the CPI process "is really quite different from other study methodologies, such as randomized controlled trials."

"Controlled trials," says Dr. Horn, "have a lot of limitations, restricting which patients can qualify, and what the processes need to be. Often, the trials do not mimic actual practice."

CPI, on the other hand, "looks at data in actual practice of care for all patients who have a problem," says Dr. Horn. "It measures how patients differ; it measures all treatments. Then the data tell you which treatments are associated with the best outcomes, controlling for patient severity differences."

"CPI allows researchers to develop decidable and executable guidelines, based on data rather than opinion," says Dr. Horn.

"Moreover," says horn, "practitioners can have confidence in CPI-based guidelines because their supporting data comes from the broad spectrum of patients seen in the routine practice of medicine, rather than from an artificially homogeneous patient sample that is customary in randomized controlled trials."

She gives an example of the confusion that can happen when randomized controlled trial results are taken as the standard.

"There was an RCT looking at how to prevent strokes - whether drugs or carotid endarterectomy surgery were better. The RCT showed better results with surgery than without," says Dr. Horn. "But, in real world practice the outcomes were much worse from carotid surgery."

How could this be? It was realized that patients in practice can have much worse problems than those in randomized trials, and the surgery was being performed by surgeons with varied training rather than those with a cardiac specialization in major teaching hospitals. The results were not comparable.

Horn has always felt that observational studies provide good information, but now has backing from the New England Journal of Medicine. Last June, two separate research groups, at Yale and the University of Iowa Medical School, reported on their studies in NEJM. They found that randomized trials and observational studies on the same medical topic had remarkably similar results.

Now, she says, CPI is being used in nearly every area of medicine. There are major studies (most multi-site) in surgery, coronary artery bypass, orthopedics, diabetes, blood pressure, stomach ulcers, arthritis, hospice, end of life care, long-term care, and pediatrics.

"One of the most recent grants is in rehabilitation medicine. TIRR just signed on to be part of that study, looking at post-stroke rehab," says Dr. Horn.

"Anybody who's involved in treating patients and discovering which processes would benefit from CPI training," says Dr. Horn. "However, when you understand what goes into these studies, very often the nurses are the ones who see multiple process steps going on. Nurses are good leaders in conducting these studies."

Over the course of the seminar (Oct. 4-6 and Nov. 1-3), healthcare professionals will learn how to conduct the whole CPI process. They will have an opportunity to begin a project, put learning to work, and apply techniques.

"It has been a major challenge," says Dr. Horn, "but it is getting easier for healthcare administrators and practitioners to understand the usefulness of CPI. Now we have enough evidence to back up the methodology."

A one-day overview ($450) is available on Oct. 4 for senior leadership - CEOs, CFOs, CIOs and medical directors. Special rates are available to TMC healthcare professionals and UT-Houston School of Nursing adjunct faculty for the four-day seminar (regularly $2,500). For information: 713-500-2024 or http://sonser4.nur.uth.tmc.edu/cpi/.

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©2006 Texas Medical Center

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