Effectiveness: Then and Now

Abstract

What treatment provides the best result for a patient? What difference does your intervention make? Is the treatment effective? Is it cost-effective? Does it work? These are questions increasingly asked by health care surveyors, regulators, colleagues, and consumers. How do we respond? What evidence do we have to support our conclusions? An innovative statistician asked similar questions more than 150 years ago. Her interventions, consisting of improving air circulation, washing walls and floors with lime, removing trash daily, unclogging drains, and removing debris from water pipes, made a difference in the outcomes of her patients. The reason we know that her interventions in the care of hospitalized soldiers were effective—producing a decrease in the mortality rate from 52% to 20%—is in large part because of her meticulous records and the dissemination of her results to individuals able to influence policy changes.1, 2 This “passionate statistician”3(p92) was Florence Nightingale, also known as the founder of modern nursing. Nightingale was one of the earliest researchers to base her recommendations on the evidence accumulated through her careful recordkeeping. Using color-coded bar and pie charts and other visual displays, Nightingale made the statistical information understandable to her audience: civil servants, administrators, politicians, and other influential policy makers.4 It is appropriate to recognize Nightingale in 2010, on the 100th anniversary of her death, for her contributions to effective, evidence-based care. Nightingale would appreciate and understand the emphasis in the current health care environment on identifying through research which interventions are most effective in treating patients. a type of health care research that compares the results of one approach for managing a disease to the results of other approaches. Comparative effectiveness usually compares two or more types of treatment, such as different drugs, for the same disease. Comparative effectiveness also can compare types of surgery or other kinds of medical procedures and tests. The results often are summarized in a systematic review.7 The AHRQ gives the example of examining the comparative effectiveness of medications used to treat depression. Comparative effectiveness researchers reviewed the studies on antidepressant medications to examine how well people's symptoms improved after they took an antidepressant. They also looked at the occurrence of side effects and summarized their findings in a systematic review.7 health care delivery systems (ranked first, initially called “Safety and Quality of Health Care”); cardiovascular and peripheral vascular disease (ranked second); eyes, ears, nose, and throat disorders; kidney and urinary tract disorders; and gastrointestinal system disorders.8 Although the topics of “safety” and body system disorders resonate with perioperative nurses, there are challenges in surgically related comparative effectiveness research initiatives. For example, one article on robotic surgery describes the relative lack of large-scale randomized trials available that could identify the effectiveness of different interventions.9 This is a common challenge for clinicians attempting to identify the best evidence-based practices. Another consideration is the need to identify whether the results of studies can be applied to the general population, for example, both adult and young men and women, and individuals with and without comorbid conditions (eg, diabetes, hypertension).10 Another issue relates to balancing both clinical benefit and statistical effects11; this is another way of saying, “Look at the patient as well as the numbers.” Surgery is art as well as science, and measuring the former is not as straightforward as quantifying the latter. Nightingale remarked, “The main end of Statistics should not be to inform the Government as to how many men have died, but to enable immediate steps to be taken to prevent the extension of disease and mortality.”12(p169) Her emphasis on using statistics as a means to formulate an effective plan could serve as the goal of comparative effectiveness research. Nightingale's use of statistics also provides direction for perioperative nurses. It is more than consoling to remember that Nightingale had little in the way of formal persuasive powers when she started her career in health care. Perioperative nurses can participate in comparative effectiveness research activities. The AHRQ stresses the need for more researchers13 and providers to disseminate, translate, and implement comparative effectiveness research.14 These are important activities that provide opportunities for taking an active role in improving care. Patricia C. Seifert, RN, MSN, CNOR, CRNFA, FAAN, is Editor-in-Chief of the AORN Journal and an education coordinator for the Cardiovascular Operating Room at Inova Heart and Vascular Institute, Falls Church, VA. Ms Seifert has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.