National Academies Press: OpenBook

Clinical Practice Guidelines: Directions for a New Program (1990)

Chapter: Definition of Appropriate Care

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Suggested Citation:"Definition of Appropriate Care." Institute of Medicine. 1990. Clinical Practice Guidelines: Directions for a New Program. Washington, DC: The National Academies Press. doi: 10.17226/1626.
Page 40

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DEFINITIONS OF KEY TERMS 40 of a set of guidelines may have no corresponding review criteria or other practice evaluation tools at all. For example, one guideline of the U.S. Preventive Services Task Force (1989:108) states that "screening for congenital hypothyroidism is recommended for all neonates during the first week of life." This statement and a subsequent one defining specific tests to be used could be directly translated into a criterion for reviewing care for a specific neonatal case or for reviewing the pattern of neonatal care provided by a practitioner or an institution. In contrast, the further statement by the Task Force that "it may be prudent to perform regular physical examinations of the thyroid in persons with a history of upper-body irradiation" (emphasis added) would be difficult to translate into a criterion for assessing either case-by-case or aggregate performance. Of course, even though certain statements about neonates could be used for medical review performance, determining that they should be so used requires a decision that the benefits of such a review in improving health or other desired outcomes warrant the administrative steps and costs that a review would entail. To cite a different example with respect to screening for hearing loss, the Preventive Services Task Force (1989:198), recommends that "screening of workers for noise-induced hearing loss should be performed in the context of existing worksite programs and occupational medicine guidelines." Such a statement may have some value for patients or clinicians without itself generating a review criterion in the context considered in this report. Definition of Appropriate Care Because the concept of appropriate care or appropriateness is crucial to the committee's definition of practice guidelines and is itself the subject of some differences and confusion in usage, the committee considered it necessary to explicitly define this concept. Brook and his colleagues at the RAND Corporation define appropriate care as follows: when "the expected health benefit [exceeds] the expected negative consequences. . . by a sufficiently wide margin that the procedure [is] worth doing" (see, e.g., Park et al., 1986:6). Conversely, care is inappropriate when the expected harms exceed the expected health benefits.4 Care may range from clearly appropriate to clearly inappropriate. Care that is not described by scientific evidence and expert judgment as either clearly one or the other may be termed equivocal. A practice might be 4 Health benefits include increased life expectancy, better functional status, and reduced morbidity, pain, and anxiety. Negative health outcomes are the opposites of these qualities. Both short-term and long-term positive and negative outcomes should be examined to determine appropriateness.

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