About Clinical Consulting

Research findings, no matter how rigorously they are obtained and in which prestigious journal they are published, may be evidence but are not an evidence base.  Compiling an evidence base requires the thoughtful and defensible integration of studies into knowledge bases that summarize, specify and critique: prior knowledge; study objectives, design, measurement, implementation, and statistical analysis; strength of evidence; and accumulated evidence.  Only then can we start addressing the so what, what if, what next, where from and where to questions - the translation of science back to clinical practice.

Clinicians like to learn from clinical experience and their won application of evidence bases.  Clinicians  like to see for themselves how advances in knowledge impact on the care of their patients.

Patients are becoming informed consumers of healthcare.  They too want to know if advances in healthcare will help them get better.  They hear and read about these new advances.  Much of this information is reliable, some of it is not.  Increasingly, they too adopt a micro-perspective: does it work for me? 

Designing evidence-based methods to support clinicians and patients in screening, monitoring, and improving health - that is the focus of MATRIX45's clinical consulting services.

Our clinical consulting services focus on this translation of scientific evidence, macro and micro, to clinicians, patients, and families - to improve health care and patient outcomes.  On our clients' behalf, we synthesize macro-evidence, develop guidelines, and communicate it all through various channels.  We apply macro-evidence into clinical support tools for use at the point of care.  Just as much, we help our clients develop processes and systems to support the (responsible) use of micro-evidence: screening, monitoring, risk assessment and profiling, outcomes evaluation, and benchmarking.  At MATRIX45, we have some neat ideas and approaches as to how this can be achieved.

At MATRIX45, we take our clinical consulting services to the next level.  What are the real world practice patterns in treating particular disease processes?  What are the associated patient outcomes?  Using methods for pattern recognition, risk adjustment, and causal modeling, can links between variability in practices and variability in patient outcomes be established?

Clients also ask for our help in synthesizing research for their internal purposes: state-of-the-science assessment, gap analysis, science-driven market positioning, product differentiation, and portfolio analysis.

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Micro- And Macro-Levels of Evidence

At MATRIX45, we make a distinction between macro- and micro-evidence.  We believe that clinicians learn from both - and that quality improvement in clinical practice is fueled by both.

Macro-evidence is scientific knowledge generated through multi-center studies (trial as well as non-trial designs) and the critical review of the findings of these studies.  It also encompasses the analysis and integration of findings across studies into reviews, meta-analyses, and practice guidelines.  Clinical learning is channeled through publications, conferences, and other education and communication methods.  Macro-evidence is about quality improvement by "seeing the larger picture" - the "many-patients" picture.

 

Micro-evidence, in contrast, is the evidence that comes from one's own clinical experience and experimentation.  It consists of the application of macro-evidence in one's own clinical practice and "seeing with one's own eyes" the impact of interventions on outcomes - the "my-patients" picture.

How can we design scientific support programs to effect "behavioral change" in clinicians - their adoption of good clinical practice patterns?  It is critical to provide clinicians and their teams with access to both levels of evidence - not prescriptively ("thou shall ...") but intuitively ("what if ..."). ?

Let's extend this macro/micro-evidence line of thought to patients and families.  Unfiltered access to medical information on the internet and in public media, and the occasional informed communication, are the macro-evidence available to patients and families.  The micro-evidence may be even more fragile and unreliable: Is this treatment helping me?  Do I feel less sick?  Would I feel more sick if I did not take my medications as the doctor prescribed?  At the patient and family level, the clinical challenge is to communicate knowledge and foster experiential learning that encourages patient responsibility and improves their persistence and compliance.

The litmus test for evidence-based knowledge in healthcare is threefold:

Does the new knowledge find its way into clinical practice: actively, through planned action; passively, through diffusion and adoption?

 

Does it improve patient outcomes?

 

Does real-world clinical practice and achieved outcomes correspond to what is known to be best?

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CASE STUDIES

Clinical consulting has figured prominently in the principals' careers.  Some examples (in the public domain):

European Survey on Anaemia Management

Anemia and Blood Transfusion in Critically Ill Patients

Building a Postmarketing Research Program on Anemia Within and Across Disease and Treatment Processes

Geriatric Best Practice Protocol Development and Hospital Performance Benchmarking

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European Survey on Anaemia Management

A practice pattern and outcomes analysis investigation, this project also sought to examine the gap between actual clinical practice and evidence-based best practice guidelines in managing anemia in patients with chronic renal failure.  Acclaimed as the first study to "put the scientific finger in the clinical practice wound", its findings have been widely disseminated and are frequently cited.  There is strong anecdotal evidence of the impact of this study on daily nephrology and dialysis practice (admittedly, hard data would be helpful).  The ESAM study was published in a special issue of Nephrology Dialysis Transplantation.

Originally conducted in Western Europe, this study was extended subsequently into Central and Eastern Europe, Israel, the Middle East, North and South Africa, Australia, West Asia, and Southeast Asia.

Clicking here will take you to an overview of the various articles and the option to download *.pdf versions of each.

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What is the impact of transfusion in anemic ICU patients (without acute bleeding)?  We worked with a team of academic investigators and biopharma staff on designing and implementing a European-wide study on transfusion management and associated morbidity and mortality outcomes: what are the practice patterns in anemia/tranfusion management and can patient outcomes be linked (causally) to these outcomes?  Transfusion was clearly associated with diminished organ function and 28-day mortality.  The study was published in the Journal of the American Medical Association, its relevance further underscored by the accompanying editorial by one of the world's foremost transfusion specialists.

Click here to download a *.pdf version of the paper published in Journal of the American Medical Association.  Click here for the accompanying editorial by Hébert and Fergusson in *.pdf.

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As the prevalence and consequences of anemia became  better understood, a comprehensive program of research was launched: across the full spectrum of chronic kidney disease, and across disease states and/or treatments that might induce anemia.

Within the spectrum of chronic kidney disease, international studies were launched to assess prevalence, determinants, practice patterns, and outcomes.  Dialysis patients were studied in the European Survey on Anaemia Management and its global extensions (see above).  Other studies in the public domain focused on patients with early renal insufficiency ("pre-dialysis") and patients who had undergone renal transplantation.  These studies were published in American Journal of Kidney Diseases (click here for *.doc copy), Nephrology Dialysis Transplantation (click here for *.pdf copy), and American Journal of Transplantation (click here for *.pdf of article and here for *.pdf of accompanying editorial).

The study on anaemia in critically ill patients (see above) was one in a series of studies on non-renal patients.  A European study focused on orthopedic patients undergoing total knee and/or total hip arthroplasty and was published in Transfusion (click here for *.pdf of article).   An international study investigated disease-related and treatment-related anemia in cancer patients, and initial findings are being released.

All of these studies documented the persistent problem of underdiagnosis and undertreatment of anemia - despite its well-known prevalence and consequences.

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Since the early 1990s, we have been involved in a nationwide effort to improve geriatric nursing care in American hospitals through best practice protocol development and hospital performance benchmarking.  This collaboration with the John A. Hartford Center for Geriatric Nursing at New York University has engendered transformational change in over 130 hospitals and has measurably impacted on staff knowledge and patient care delivery.  Please visit the Institute's website for more information.

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Clinical research program development and implementation

Clinical practice pattern and outcomes analysis

Clinical practice guideline development and evaluation

Clinical algorithm development and evaluation

Review of scientific literature and knowledge synthesis

Performance benchmarking

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