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PubMed1999

A critical evaluation of clinical practice guidelines in neonatal medicine: does their use improve quality and lower costs?

Clinical practice guidelines and care pathways have become a focus of quality improvement efforts in Neonatology. Health care administrators believe that using clinical practice parameters reduces health care costs, improves quality of care, and limits malpractice liability. Practice guidelines and surveys of consumer satisfaction have grown in use partly because third-party payers, insurers, and health maintenance organizations, as well as hospital administrators bent on reducing variable costs of care and contracting for capitated care have championed their development, implementation, and monitoring. Overall there is minimal evidence-based medicine to support that neonatal outcomes have benefitted from their implementation, although some studies show affirmative effects in limited populations or in a limited number of centres. For highly autonomous physicians and nurses this standardization of medical decision making may represent a difficult transition into efforts to improve quality, based on evidence-based care, and in some instances into corporate medicine. By realigning the traditional values of patient relationships, including parent involvement, the implementation of guidelines has been fast-tracked in some institutions, without appropriate audit to determine their effectiveness in achieving their goals. However, because guidelines and clinical pathways are here to stay, neonatologists need to think critically about how their content and method of implementation, monitoring and modification may influence medical and nursing teaching and decision making in the future. If guidelines are introduced primarily as a cost savings or containment tool that ignores their impact on the quality of medical care and thereby restricts needed care, then neonatologists must be quick to challenge the potentially damaging and inappropriate use of guidelines and care pathways. Several international efforts are underway to study both the impact of evidence-based guidelines and to determine if they can be imported from one care system into another. Furthermore, there are many medico-legal implications of guideline and clinical pathway implementation that may not favour physicians and other neonatal care practitioners, and leave to hospitals, insurers, and ultimately the courts, decisions regarding evidence-based care. Neonatologists and other practitioners in neonatal care centres should critically analyse the goals of guideline development, implementation and monitoring and should restrict themselves to guideline directed care only at those practices for which there is evidence supporting their implementation and continuous monitoring.

Consumer Behavior↗
PubMed1997

Clinical practice guidelines in pediatric and newborn medicine: implications for their use in practice.

Clinical practice guidelines are becoming pervasive in pediatrics and newborn medicine. They have spanned a wide range of primary care practice parameters from treating otitis media with effusion, to performing complex surgery for congenital heart disease, and management of respiratory distress syndrome and coordinating discharge from the neonatal intensive care unit. Administrators believe that using clinical practice parameters reduces health care costs, improves quality of care, and limits malpractice liability. Practice parameters and guidelines have grown in use because powerful interests-third-party payers, insurers, and health maintenance organizations, as well as hospital administrators bent on reducing variable costs of care and contracting for capitated care-champion their development, implementation, and monitoring. Economic credentialing of physicians with excessive variances without risk-adjusting for other than average patients is problematic and remains unchecked partly because of the fundamental characteristics of the evolving health care industry in which costs are more easily measured than quality. For highly autonomus physicians this standardization of medical decision making may represent a difficult transition into corporate practice by realigning traditional values of the doctor-patient relationship. However, because guidelines are almost certainly here to stay, pediatricians and neonatologists need to think critically about how their content and method of implementation, monitoring, and modification may influence medical teaching and decision making in the future. If guidelines are introduced primarily as a cost savings or containment tool that ignores the impact on the quality of care and restricts necessary care for infants and children, especially those with chronic illness or who are developmentally at risk, then neonatologists and pediatricians must be quick and determined to challenge the potentially damaging use of practice parameters or guidelines. Furthermore, there are many medicolegal implications of guideline implementation that may not favor physicians and leave to hospitals, insurers, and ultimately the courts decisions regarding evidence-based practice. In this review article, we pay special attention to the guidelines developed in newborn medicine. We discuss why and how guidelines are developed and critically evaluate the available evidence describing potential benefits and drawbacks of guidelines in general. There are legal implications to the implementation of guidelines, and guidelines may increase provider susceptibility to malpractice allegations. Neonatologists and pediatricians should critically analyze the following questions when guidelines are being developed: Are clinical practice parameters the most effective means to reduce the costs of health care, or improve the quality of health care services while reducing the need for and protecting physicians from malpractice suits? Or do clinical practice guidelines more closely resemble an audit system developed by health care organizations, insurers, and others including government-sponsored health care to appease powerful interests-with limited evidence for promise and perhaps potential negative cost, quality, and malpractice liability implications? In pediatric and newborn medicine there is limited evidence that guidelines have achieved the desired goals and further analysis of their process of care and the costs of implementation is warranted.

Health Services↗