use of hematopoietic growth factors was sharply reduced in one managed care organization by the institution of a simple accountability system. Before administering growth factors, physicians had to call the administrator and report the indication for its use (J.E. Katterhagen, personal communication to Thomas Smith, 1998).

AHCPR Cancer Pain Management Guidelines. Recent studies suggest that as many as one in four cancer patients is given inadequate pain relief (Rischer and Childress, 1996). Adherence to the 1994 AHCPR guideline on cancer pain management, following its widespread dissemination, was assessed in seven acute care hospitals in Utah in 1995 and again in 1996 (Rischer and Childress, 1996). On most process measures, care improved, but outcomes (e.g., pain scores) were not assessed (Table 6.7). A limitation of this study is the absence of a concurrent control group that was not exposed to the guideline dissemination intervention. Without such a group, one cannot attribute improvements to the guidelines. The program to improve pain management according to the AHCPR guideline has been implemented throughout Utah.

TABLE 6.7

Compliance with Core Guidelines

Guideline

Prea

Postb

p Value

Opioids Prescribed

99

100

1.000

Initial Pain Assessment

Rating Scale Used

64

79

.090

Ongoing Pain Assessment

Pain rating scale repeated at regular intervals

27

74

<.001

Efficacy reported

83

97

.011

Analgesic Use

Pain medicines on regular schedule

70

91

.003

Bowel Treatment Plan

Laxatives ordered

66

69

.857

Education of Family or Patient

Education about cancer pain

6

34

<.001

Written education

16

26

.238

Patient Satisfaction Evaluated (not actual patient satisfaction)

24

97

<.001

NOTE: Ten patients were assessed at each of seven hospitals; n = 70.

a Pre = before guideline was issued.

b Post = after guideline was issued.

SOURCE: Rischer and Childress, 1996.

American Urologic Association Early Prostate Cancer Guideline. The American Urologic Association recommended in 1995 that patients with localized prostate cancer be offered surgery, radiation, or surveillance as treatment options. To assess compliance with the guideline in the



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