Guidelines for Clinical Practice From Development to Use (1992) / Chapter Skim
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SUMMARY
Pages 1-22
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From page 1... ...
A committee of experts in clinical practice, health care policy and administration, health services research, and related fields met five times between June 1990 and September 1991 to develop this report.) 1 Committee activities and sources of information included site visits, a public hearing, focus groups, commissioned papers, and published and unpublished literature.
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WHAT ARE PRACTICE GUIDELINES? As defined in the IOM's 1990 report, practice guidelines are "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances." Medical review criteria, which are also discussed in this report, are "systematically developed statements that can be used to assess the appropriateness of specific health care decisions, services, and outcomes." Practice guidelines focus, in the first instance, on assisting patients and practitioners in making decisions, but this defining characteristic does not and should not preclude their use for other purposes including quality improvement and payment policymaking.
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Whether the issue is unexplained variation, inappropriate care, or uncertain outcomes, many analysts come to similar conclusions. More research on outcomes and effectiveness of health care services is needed; more effort should be invested in using such research to formulate specific guidelines for clinical practice; more use of the resulting guidelines will help limit spending for health services.
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The result should be better value, but the net impact on the rate of increase in total health care spending cannot be predicted with confidence, even if future priorities for guidelines development stress clinical conditions for which costly overuse of services is suspected. In sum, guidelines for clinical practice are a promising but not a quick or sure strategy for improving and rationalizing the overall use of health services.
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A fourth strength is that researchers, clinicians, educators, and managers are being stimulated to consider how guidelines and other efforts to improve the quality and efficiency of health care can support and complement each other. These efforts include outcomes and effectiveness research, methods for strengthening informed patient decisionmaking, and both traditional and newer techniques for quality assessment and quality improvement.
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Many national organizations involved actively in developing guidelines and review criteria are moving to improve their programs, but weak procedures and products are common. Methods and procedures for local adaptation of national guidelines and for translation of guidelines into medical review criteria have not been thoroughly documented, but they certainly appear to be subject to equal or greater weaknesses.
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The IOM has specified desirable attributes of clinical practice guidelines and medical review criteria (Tables 1 and 2~. Each attribute affects the likelihood that guidelines will be perceived as trustworthy and usable or the probability that they will, if used, help achieve desired health outcomes.
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if- given the same evidence and methods for guidelines development-another set of experts produces essentially the same statements and (2) if given the same clinical circumstancesthe guidelines are interpreted and applied consistently by practitioners (or other appropriate parties)
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Review criteria are specific if it is highly likely that they will identify truly good care as such. Review criteria should specifically identify a role for patient preferences or ensure that the process for using them allows for some consideration of patient preferences.
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In fact, few guidelines today provide any formal projections of health benefits and harms, any explicit treatment of patient preferences, or any estimates of the cost implications of their recommendations, certainly not in comparison with alternative practices. Most also lack explicit assessments of the strength of the evidence behind their recommendations.
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. Such testing may not conform to the highest standards of experimental research design, but it can provide a systematic, practical, and direct means of identifying where guidelines as well as clinical practice may need revision.
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The issues relating to dissemination are many, and the committee did not explore them in depth. Certainly, dissemination alone will neither induce the use of the information being disseminated nor change behavior, and excessive distribution of information exacerbates information overload.
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After much debate, the committee concluded that every set of guidelines need not be based on formal judgments of cost-effectiveness; sound guidelines for clinical practice can stand on rigorous assessments of clinical evidence and carefully derived expert judgment. In addition, the committee declined with some dissent to recommend that guidelines must include statements of what constitutes minimum or required care for particular clinical problems.
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These guidelines would supplement condition- or treatmentspecific practice guidelines, on the one hand, and legally oriented patient consent forms, on the other. Such "patient information guidelines" should be developed by a systematic process similar to that described for clinical practice guidelines.
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Guidelines that have been accepted by those responsible for providing care, financing care, and monitoring care in the public interest are one means of bridging the chasm between internal and external quality assurance strategies. With respect to models of continuous quality improvement, the committee urges that their focus on systems problems, strong customer-supplier relationships, improvement of average performance, and reduction of variation be more systematically and explicitly joined with an effort to apply and improve sound guidelines for clinical practice.
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Some approaches may be more or less confined to third-party payers whereas others may be shared by health care institutions, quality review programs, and others. 2 The committee explicitly recognizes the need for protection of privacy and confidentiality as those concepts are understood in usual quality assurance terms (e.g., in actions of Medicare peer review organizations, state medical licensure boards, hospital quality assurance committees, and the like)
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Consistent with quality improvement principles, they can then stress education and feedback to physicians aimed at improving practice rather than punishing errors. Risk Management and Medical Liability Guidelines that are based on available scientific evidence and that are clear, specific, and developed by a reputable process should carry greater weight in malpractice decisionmaking than vague, nonspecific guidelines that lack documentation and careful reasoning.
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The committee also supports efforts of the library to expand its capacity to assist in guideline development through expansion of its Office for Health Services Research Information. In addition, the committee favors the translation and movement of guidelines into computerized decision aids of various sorts.
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improved use of scientific evidence and expert judgment in malpractice cases and stronger assurance for practitioners that compliance with sound guidelines would reduce their exposure to medical liability. The minimum conditions for the successful operation of an assessment organization were relatively easy to identify: effective demand for the product (that is, the assessments)
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The assessment organization should be oriented toward a broad set of potential users of guidelines. Nonetheless, its assessments should be pa'^ticularly attuned to everyday clinical practice and sensitive to practitioners' reliance on their professional societies for guidance and support.
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Finally, the committee notes that the clinical and health services research communities have an important role to play in smoothing the path from clinical research to better clinical practice and improved health outcomes. If more attention is paid to testing the effectiveness of procedures and patient management strategies in real-life settings rather than only assessing efficacy in highly controlled clinical trials, then developers of guidelines will be more likely to have a knowledge base with greater practical relevance.
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Some proposals for reform include provisions for cost containment that incorporate roles for clinical practice guidelines in defining or administering basic benefit packages, strengthening health plan competition and consumer choice, or restructuring malpractice decisionmaking. The specifics vary, but the basic ideas are that the reforms would do one or more of the following: override state benefit mandates, circumvent court-ordered coverage in individual cases, rewrite malpractice laws, reduce administrative costs through national or regional administrative and regulatory structures, and limit the coverage eligible for tax deductibility.
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