Guidelines for Clinical Practice From Development to Use (1992) / Chapter Skim
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5 IMPLEMENTATION: QUALITY, COST, AND RISK MANAGEMENT
5 IMPLEMENTATION: QUALITY, COST, AND RISK MANAGEMENT
Pages 99-134
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From page 99... ...
Perhaps the most appealing rationale for the development and use of clinical practice guidelines is that they can help improve the quality of health care; certainly, it is the most positive and optimistic reason to invest time, resources, and energy in guidelines development. The first section of this chapter thus focuses on programs to assess, assure, and improve the quality of care and on the potential role that guidelines might have in this area.
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From page 100... ...
Good practice guidelines have the potential to contribute in each area. First, guidelines and review criteria that explicitly and clearly describe appropriate care for particular clinical problems provide a solid base for detecting Patterns of overuse or underuse.
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From page 101... ...
Clinical practice guidelines, medical review criteria, and standards of quality relate more directly to the processes of care than to outcomes because they describe what constitutes appropriate management of specific clinical problems. Performance measures describe the data needed to evaluate whether actual behavior conforms to guidelines, criteria, and standards.
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From page 102... ...
74~. A recent American Hospital Association survey states that more than 40 percent of reporting hospitals say they are engaged in continuous quality improvement (Utilization Review Newsletter, l991b)
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From page 103... ...
to reduce the opportunity for error and to link specific care processes to health out comes; · feedback to practitioners of statistical information on how their practices may differ from those of their peers or depart from evidence-based standards for practice; · visible commitment to quality by the top leadership of the organization and involvement by all parts of the organization in processes of quality improvement; and a striving for continuous improvement in contrast to simply achieving preset goals. Within this framework, sound practice guidelines and medical review criteria have several possible uses.
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From page 104... ...
A number of CQI techniques are designed to uncover such process flaws and to structure activities to correct them. Moreover, because CQI generally tends to have a "quantitative" emphasis and to be detail oriented, it may encourage those who design practice guidelines and medical review criteria to be more explicit, specific, and comprehensive with respect to the clinical content of guidelines and to better anticipate and confront the practical problems that may face prospective users of guidelines.
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From page 105... ...
For example, in a recent article examining CQI concepts and applications for physician care, the only reference to practice guidelines occurred in a discussion on the need for chart review and other monitoring activities to supplement CQI (Kritchevsky and Simmons, 1991~. Among the hospitals visited during this study, several were using or trying to develop clinical protocols or pathways that specified the sequence and timing of various interventions for different clinical problems; the object was to standardize practice and reduce errors.
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From page 106... ...
As credible and relevant practice guidelines become more available and more widely known, they should be perceived as more relevant to those attempting to implement quality improvement models in health care settings. Medical Review Criteria Although CQI programs may emphasize professionalism and internal quality improvement rather than regulation and external inspection, both 5 One result is a thriving business for consultants as health care institutions call on them for assistance in understanding and using the CQI model.
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From page 107... ...
Review programs may add to as well as subtract from particular practice guidelines. As a case in point, review programs directed at patterns of care may employ quantitative thresholds that do not appear in guidelines to assist individual patient or practitioner decisionmaking.
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From page 108... ...
Selected Illustrative Activities Related to Medical Review Criteria Public Sector Medicare peer review organizations have for the past few years been expected to carry out a variety of utilization review activities, chiefly preprocedure and preadmission review as well as some retrospective review (IOM, 1990i, see especially vol.
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From page 109... ...
. Consistent with its charge to arrange for the development of medical review criteria as well as practice guidelines, AHCPR in August 1991 issued a request for proposals (REP)
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From page 110... ...
Specifically, the committee urges the following: · Guidelines, medical review criteria, and other evaluative tools should be used both to improve average performance and as is still importantidentify substandard performance. · Analyses of how individual practice patterns differ from average patterns should go beyond statistical analysis to consider relevant practice guidelines as benchmarks for performance.
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From page 111... ...
In addition, the committee recognized the controversy that has developed over the use and content of medical review criteria, and consequently identified several desirable attributes of such criteria. These eight attributes are analogous to those described in Chapter 1 for clinical practice guidelines.
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From page 112... ...
That kind of attention is a major source of anxiety for professional groups that are involved in developing guidelines and for individual professionals who are exposed to payer efforts to influence practice in conformity with guidelines.
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From page 113... ...
The following sections discuss how these cost-management strategies may support and be supported by practice guidelines and review criteria. One section discusses legal liability issues for third-party payers and others, particularly as these issues relate to decisions about payment.
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From page 114... ...
9 In one of the better-known cases on the liability of utilization review organizations, Wilson v. Blue Cross of California (222 Cal.
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From page 115... ...
Medical Review Criteria and Managing Benefit Costs The general issues in medical review discussed earlier are also relevant to the use of medical review criteria in programs to limit payment for medically unnecessary or inappropriate care. For both quality assessment and cost containment purposes, review programs have relied primarily on retrospective utilization review (i.e., review after care has been provided)
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From page 116... ...
care are considered, the results are mixed. In any case, the availability of sound guidelines for clinical practice and their competent translation into criteria, software, and other elements of a review program are clearly critical for the effective, responsible use of utilization review programs.
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From page 117... ...
In other cases, courts have more fundamentally challenged the judgments of plan administrators, declaring certain determinations as inconsistent with expert medical judgment on the basis of de novo judicial review of the evidence. The cases have involved what the health plans have deemed noncovered "experimental" or "investigational" services including some types of autologous bone marrow transplants, radial keratotomy, and "coma arousal" programs: See, for example, Pirozzi v.
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From page 118... ...
The issue of negligent setting or selection of standards by the review organization apparently has not been raised. Overall, prudence dictates that those developing guidelines or review criteria and those applying them in medical review programs should expect to be held legally accountable for their actions and should manage their affairs accordingly.
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From page 119... ...
Health benefit plans and health care institutions that somehow select or "credential" practitioners have several opportunities to encourage the application of practice guidelines.~3 For example, they can make employment, participation, or privileges contingent on a practitioner's prior agreement to practice in accord with the organization's clinical policies. Among the sites visited by the study committee was a group of primary care clinics that employed physicians with the understanding that they would practice in 13 A variant on this theme is for the employer, rather than a health care institution, HMO, or insurer, to hire or contract with practitioners directly to provide routine health care services to employees.
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From page 120... ...
The committee knows of no good evidence on the subject, but it suspects that profiling based explicitly on clinical practice guidelines is less common than simpler profiling based on utilization rates or levels.~4 To the extent that credentialing, selective contracting, and similar strategies work well and are supported by ongoing health plan structures and processes, they presumably should bring into health plans and institutions those practitioners who are already committed to the desired practice patterns and then help to maintain that commitment. To maintain or redefine desired performance, other strategies are necessary.
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From page 121... ...
This question is explored in the next chapter. Other Economic Incentives Many health plans and public programs use explicit financial incentives to influence practitioner or patient behavior without explicitly attempting to encourage specific appropriate care and discourage specific inappropriate care (Brook, 19911.
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From page 122... ...
Potentially, the guidelines could be incorporated into the health plan contract itself and referenced by specific name or they could be developed according to a process defined in the contract. This contract-based strategy would offer direct economic incentives to the consumer in the first instance, with provider behavior affected as a consequence.
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From page 123... ...
RISK MANAGEMENT, MEDICAL LIABILITY, AND PRACTICE GUIDELINES Given the context in which clinical practice guidelines are being promoted, concerns about medical liability loom large. Any strategy to encourage the application of sound guidelines ought to consider the opportunities and obstacles presented by risk management programs and medical liability reforms.
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From page 124... ...
Across health care institutions, risk management programs and quality assurance programs are generally distinct organizational functions with varying degrees of interaction (Donaldson and Lohr, 1990~. The wider availability and application of clinical practice guidelines should provide a stimulus for closer coordination.
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From page 125... ...
Fourth, if practitioners have confidence in particular clinical practice guidelines and expect that documented conformance with these guidelines will do much to protect them against unwarranted claims (and findings) of malpractice, the anxieties that give rise to defensive medicine should diminish and the willingness to apply guidelines should increase.
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From page 126... ...
Some argue that the potential of guidelines to reduce defensive medicine, improve decisions in liability cases, and discourage unwarranted claims cannot be adequately realized unless courts accord clinical practice guidelines more weight than they currently do in determining the standard of care to be applied in assessing claims of malpractice (Hall, 1989; Brennan, l991b; McCormick, 1991~. This committee agrees generally with that proposition.
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From page 127... ...
. Whether this will and should change and how practice guidelines will figure in any change are issues in the general discussion of the role guidelines should have in determining medical liability (Hall, 1989; Morreim, 1989)
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From page 128... ...
. It is in the guise of learned treatises that clinical practice guidelines can be cited as evidence.
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From page 129... ...
SOURCE: This table was suggested by Arnold J Rosoff in a discussion of legal implications of practice guidelines.
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From page 130... ...
More explicit and more controversial than the PRO immunity provision is the approach taken by the state of Maine. The state legislature has initiated a 5-year demonstration project to produce "standards of practice designed to avoid malpractice claims and increase the defensibility of the malpractice claims that are pursued" (Edwards, 1991, p.
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From page 131... ...
particular practice guidelines in their contracts, or the contracts could provide for the application of guidelines developed according to specific procedural and substantive crite
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From page 132... ...
The committee vigorously debated whether to recommend that federal or state legislation grant immunity to practitioners acting in conformance with practice guidelines. Although some members argued quite forcefully that such a recommendation was warranted now, the committee on balance concluded that it would be premature.
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From page 133... ...
The committee urges AHCPR to continue to support scientifically meritorious research on medical liability that could simultaneously examine topics related to guideline development. One question the agency might consider is whether clinical practice guidelines for services of unclear or very marginal benefit could be phrased and explained in ways that would reduce the likelihood of defensive medicine.
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From page 134... ...
In considering these supportive programs, this chapter and the next underscore a theme of this report: successful implementation of guidelines begins with the process of developing guidelines. The more developers of guidelines can anticipate what will make guidelines practical and credible, the more likely it will be that guidelines will be used in the kinds of activities described here.
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