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PubMedDate not supplied

Practice guidelines and quality: is there a connection?

Yes! Practice guidelines are clearly connected to quality. To characterize that connection adequately, however, is a more formidable task and is the subject of this paper. This paper will capture, in a few words, the essence of my perspective and experience related to quality issues and then attempt to establish a connection between practice guidelines and quality from two perspectives: first, by suggesting a series of assumptions that would lead to a decision on what should be the focus of an appropriate guideline for an older adult, since there are many possibilities and agreeing on assumptions is a logical first step; and second, by suggesting a framework for the content of such guidelines.

Aged↗

PubMed1997

Development, use, and evaluation of clinical practice guidelines.

The development and use of practice guidelines, if framed as recommendations for best practices in the prevention, diagnosis, treatment, and management of occupationally related health concerns and disability, can improve the quality of occupational medical practice and worker health and well being. Adherence to guidelines should improve the efficiency and effectiveness of prevention, care, and disability management by reducing the present wide variance in practices and then by moving the mean or median of process and outcome statistics toward recommended levels. The information developed for guidelines can also be used for patient discussion and expectation management. Practicing in evidence-based, agreed-upon ways should also make occupational medical practices more defensible. Guidelines should be explicit, be based on a review of the available evidence and benefits vs risks, have clear medical logic, link findings to diagnosis to treatment ot prevention, be time-based, and avoid recommending unproven approaches as a last resort. If possible, they should be reviewed and tested for usability. Guidelines that start with common occupational health concerns are best suited to prevention and outpatient care, because patients present in this way. The contents of a useful occupational health guideline would include a statement of purpose and scope, the method of development; the authors' and reviewers names and affiliations; an analysis of the specificity, sensitivity, and predictive power of mechanisms of illness or injury, symptoms, signs and tests; findings that point to a serious or emergent condition requiring immediate referral or treatment; diagnostic criteria; and initial treatment, including work with the patient in a therapeutic partnership. The guideline should also present information on factors known to be associated with work, and predictors of delayed recovery. Disability-duration statistics and methods of matching job requirements with worker abilities are also helpful. Guidelines should then outline reassessment of those patients whose health concerns remain after a reasonable recovery period. The recommendations should again be evidence-based and conform to the other attributes listed above. A discussion of management after reassessment, including behavioral referral, further testing, and procedures, is also quite useful. Recommendations for restoration of function and return to work complete guidelines focused on diagnosing, treating, and resolving activity limitations among workers. Simply developing and publishing guidelines has not resulted in improvement in practice. However, if used as the basis for peer-group interactions and actions by occupational health opinion leaders, guidelines can contribute to marked improvements in quality, worker satisfaction, and worker health.

Cost-Benefit Analysis↗

PubMed1997

Diagnosis and management of group A streptococcal pharyngitis: a practice guideline. Infectious Diseases Society of America.

This is the second in a series of practice guidelines commissioned by the Infectious Diseases Society of America through its Practice Guidelines Committee. The purpose of these guidelines is to provide assistance to clinicians when making decisions on treating the conditions specified in each guideline. The targeted providers are pediatricians, family practitioners, and internists. The targeted patients and setting for the acute pharyngitis guideline are pediatric, adolescent, and adult outpatients with a complaint of sore throat. Funding was provided by the IDSA. Panel members represented experts in adult and pediatric infectious diseases. The guidelines are evidence-based. A standard ranking system was used for the strength of the recommendations and the quality of the evidence cited in the literature reviewed. The document has been subjected to external review by peer reviewers as well as by the Practice Guidelines Committee and was approved by the IDSA Council. An executive summary, algorithms, and tables highlight the major recommendations. Indicators of quality will assist in guideline implementation. The guideline will be listed on the IDSA home page at http://www.idsociety.org.

Adolescent↗

PubMed1993

Reducing lengths of stay for patients hospitalized with chest pain using medical practice guidelines and opinion leaders.

There are few available data on the effectiveness and safety of medical practice guidelines when used for patient care in the coronary and intermediate care units. The aim of this study was to examine the effect of educating physicians about practice guidelines to promote shorter lengths of stay for "low-risk" patients hospitalized with chest pain. Such guidelines were disseminated to physicians working in a health maintenance organization (HMO) by educational conferences, written memoranda, endorsement by opinion leaders, concurrent written feedback, and nursing-to-physician cues. A total of 208 patients were enrolled in the study. Following implementation of the practice guidelines, hospital lengths of stay were reduced from 2.51 +/- 2.1 to 1.96 +/- 1.3 days (22% reduction, p = 0.03) and intermediate care unit lengths of stay from 33.9 +/- 19 to 28.2 +/- 14 hours (17% reduction, p = 0.02) for patients with low-risk chest pain. The reduction in length of stay for patients with low-risk chest pain exceeded reductions in stay for patients hospitalized with cardiac conditions for which no guidelines were introduced. None of the patients treated according to guideline recommendations had unexpected "life-threatening" adverse events in the 2-week period after hospital discharge (95%, confidence interval 0%, 3%). This study supports the effectiveness and possible safety of practice guidelines to reduce lengths of stay for patients with low-risk chest pain.

Aged↗

PubMed2002

Role of JCAHO standards and clinical practice guidelines in promoting appropriate antimicrobial use.

The role of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards and clinical practice guidelines in promoting appropriate antimicrobial use and the development of such standards and guidelines are described. JCAHO is committed to continuously improve the safety and quality of patient care. Reducing antimicrobial resistance in health systems often requires change, something that many health care practitioners are reluctant to embrace. Current JCAHO standards suggest that the use of clinical practice guidelines be considered, but guideline use is not required. JCAHO's standards development process is lengthy and involved. Therefore, it is easier to effect change by modifying the statements of intent that accompany the standards than the standards themselves. Concerns about antimicrobial resistance can be addressed through performance measurement. In July 2002, core measures of patient care processes and outcomes will be implemented for the first time. JCAHO requires hospital laboratories to be accredited, which increases the stature of the laboratory in the eyes of hospital administration. JCAHO laboratory standards directly relate to clinical practice guidelines, antimicrobial resistance, and NCCLS (formerly known as the National Committee for Clinical Laboratory Standards) and support efforts to reduce inappropriate antimicrobial use. Hospital laboratories play a vital role in effecting change in antimicrobial use. JCAHO laboratory standards for clinical practice guidelines and quality control support efforts to reduce inappropriate antimicrobial use. Hospitals have been reluctant to require the use of clinical practice guidelines in JCAHO standards, although guidelines promote appropriate antimicrobial use and reduce antimicrobial resistance. Pharmacists should work with laboratory staff and JCAHO to effect the changes needed to stem antimicrobial resistance.

Anti-Infective Agents↗

PubMed1994

Evaluating the message: the relationship between compliance rate and the subject of a practice guideline.

To explore the relationship between providers' compliance and some key aspects of the clinical messages in practice guidelines, studies published in the English language medical literature between 1980 and 1991 were retrieved through MEDLINE and through relevant review articles in the field. All published studies providing compliance rates with practice guidelines and endorsed by official organizations were eligible for the study. The clinical content and the reported compliance rate were gathered for each recommendation in the 23 studies selected. The medical and surgical procedures addressed by 143 recommendations were identified according to specialty area, type of procedure (diagnostic, surgical, etc.) and were independently classified by the authors as being high or low on characteristics thought to influence diffusion:complexity, trialability and observability. The mean compliance rate with the 143 clinical recommendations was 54.5% (95% CI: 50.2%-58.9%), with those in the specialty areas of cardiology and oncology showing the highest compliance (mean 63.6% and 62.2%, respectively). Recommendations concerning procedures with high complexity had lower compliance rates than those low on complexity (41.9% vs. 55.9%; P = 0.05), and those judged to be high on trialability had higher compliance rates than those low on trialability (55.6% vs 36.8%; P = 0.03). Overall, all the characteristics of the clinical recommendations considered in the practice guidelines could account for no more than 47% of the observed variability in compliance rates. The target area of practice and the complexity and trialability of the recommended procedure appear to be useful, if partial, predictors of the level of compliance with a practice guideline.

Cardiology↗

PubMed1994

Medical practice guidelines.

Prescriptive standards of clinical conduct--practice guidelines--have proliferated throughout medicine over the past decade. Practicing physicians are confronted with a plethora of guidelines developed for different purposes by a diverse body of public and private organizations. We review factors contributing to the growth of guidelines, their desirable features, and consequences, legal and otherwise, of implementing guidelines. Few studies have examined whether, and under what conditions, guidelines are effective in changing physicians' practices and patients' health. Nonetheless, expectations for guidelines remain high because they are one of the only instruments of health care reform that promises to improve the quality of care while reducing overall health care costs. Efforts to develop guidelines are likely to continue unabated for the foreseeable future. Additional research comparing different methods of developing and disseminating guidelines is needed.

Practice Guidelines as Topic↗

PubMed1994

The use of practice guidelines in Wisconsin for liability protection.

It seems many physicians and other health care professionals are reluctant to advocate that the use of clinical guidelines be expanded because of negative experiences with managed care entities that have based their practice guidelines on economic considerations. Those experiences have led to the erroneous belief by some that all guidelines are minimal or substandard. The trend is clear, however, that clinical practice guidelines will be increasingly important not only in courts but also in the management of health care. They are here to stay and they provide the medical profession with an opportunity now more than ever to decide its own destiny in medical malpractice litigation without the need for new legislation in Wisconsin. Accordingly, physicians should become pro-active at medical staff departmental meetings, in local and national professional associations, and, if necessary, in the political arena to encourage the adoption of valid guidelines--those that meet acceptable medical standards. In this way the risk that practice guideline use will become both the maximum and minimum standard of care will remain only a theory. While the decision to use clinical practice guidelines is solely up to a physician, he or she should be aware of a guideline's recommendations for any given patient situation. Ideal practice can still be followed by bad outcomes that prompt patients to claim negligence. By choosing a valid guideline and making a reasonable attempt to follow that guideline, a physician has maximized his or her opportunity for both preventing and prevailing in litigation. If, however, a guideline exists and it is unintentionally ignored, liability is more likely.(ABSTRACT TRUNCATED AT 250 WORDS)

Health Care Reform↗

PubMed2002

Evidence-based practice guidelines--one way to enhance clinical practice.

Abdominoplasty and liposuction guidelines are just two of the guidelines that can be accessed and used to enhance patient care. Guidelines also can be used to increase your knowledge about many other health care topics. The NGC has approved guidelines for managing chronic pain, as well as guidelines on chronic diseases (e.g., diabetes mellitus, hypertension, chronic obstructive pulmonary disease). Many patients have chronic diseases, and you or your family members also may be affected by chronic disorders. These guidelines provide you with a quick overview of evidence-based treatment protocols. These guidelines are not a panacea for evidence-based practice, but using them is one way that perioperative nurses can enhance their clinical skills. Though not everyone has personal Internet access, most health care facilities do or can make access a reality. Other options include medical or public libraries. Then one simply has to access the NGC web site and join other professionals in improving the quality and timeliness of patient care.

Adult↗

PubMed1999

Practice guidelines for inflammatory bowel disease: an instrument for assessment.

The development of practice guidelines is problematic because guidelines that are too broad have no value and guidelines that are highly specific cannot address the nuances of every patient's illness. In this article, we present the hypothesis that practice guidelines that provide specific objectives for assessment and intervention in inflammatory bowel disease can be used to measure practice variation. These guidelines are proposed as 15 specific objectives with options for intervention. These objectives could be used as an instrument to quantify variations in clinical practice and to assess the benefits of practice guidelines.

Diagnosis, Differential↗

PubMed1991

Compliance with medical practice guidelines: the case of home oxygen.

Standard and straight forward practice guidelines for administration of home oxygen therapy have been long established and widely accepted. Medical records for 418 patients prescribed home oxygen through hospital-based programs at seven Veterans Administration medical centers (VAMCs) were reviewed to determine compliance with practice guidelines at the time of initial and current prescriptions. Rates of appropriate prescription at some VAMCs were very high but were too low at other VAMCs, especially given the criteria's simplicity and clarity. Practice guidelines should be implemented in conjunction with regular review mechanisms or other controls in place to ensure compliance.

Clinical Protocols↗

PubMed2003

Ethnic specific recommendations in clinical practice guidelines: a first exploratory comparison between guidelines from the USA, Canada, the UK, and the Netherlands.

OBJECTIVES: To investigate whether clinical practice guidelines in different countries take ethnic differences between patients into consideration and to assess the scientific foundation of such ethnic specific recommendations. DESIGN: Analysis of the primary care sections of clinical practice guidelines. SETTING: Primary care practice guidelines for type 2 diabetes mellitus, hypertension, and asthma developed in the USA, Canada, the UK, and the Netherlands. MAIN OUTCOME MEASURES: Enumeration of the ethnic specific information and recommendations in the guidelines, and the scientific basis and strength of this evidence. RESULTS: Different guidelines do address ethnic differences between patients, but to a varying extent. The USA guidelines contained the most ethnic specific statements and the Dutch guidelines the least. Most ethnic specific statements were backed by scientific evidence, usually arising from descriptive studies or narrative reviews. CONCLUSION: The attention given to ethnic differences between patients in clinical guidelines varies between countries. Guideline developers should be aware of the potential problems of ignoring differences in ethnicity.

Asthma↗

PubMed1999

Practice guidelines and tort reform: the legal system confronts the technocratic wish.

Recent scholarly writing has argued that the advent of managed care within the health policy arena can be seen as a contemporary manifestation of a broader set of concerns focusing on how objective decision procedures become politically legitimated--what one recent commentator has characterized as a faith in the technocratic wish. In the 1990s, this faith in objective decision procedures has manifested itself through the emergence of outcomes assessment and the development of practice guidelines. Notably, a few states have sought to couple the practice guidelines movement with tort reform by enacting demonstration projects permitting physicians to introduce evidence that they followed practice guidelines as an affirmative defense. In this article, I argue that even though the introduction of practice guidelines may promote the policy objective of cost-effectiveness in the delivery of health care services, their use to establish culpability in actual cases may be more difficult because the structure of legal reasoning focuses on the particular facts in the case at hand rather than appealing to abstract decision procedures. By highlighting the potential difficulties of invoking practice guidelines in the adjudication of actual malpractice cases, I demonstrate how a process of ongoing political negotiation will be necessary if the technocratic faith in practice guidelines is to become justified in reality.

Cost-Benefit Analysis↗

PubMed1996

Physicians' view of practice guidelines. A survey of Italian physicians.

After more than 10 years of development, two different views of practice guidelines are emerging: either as an educational tool for the medical profession, or as a forum where health care issues can be debated by physicians and non-medical groups. Physicians use practice guidelines in the former model to set their own standards of good quality care, while the latter approach needs contributions from other components in order to decide what should be provided by our health care systems. In a survey of Italian physicians' opinions and attitudes toward practice guidelines, responders supported the "narrowest" model. More than 80% stated that improvement of quality of care and reduction of variation in clinical and practice styles should be the aim of practice guidelines, without representatives from outside the medical profession being involved (61%, 79% and 86% disagreed with a possible involvement, respectively, of patients, health care administrators and representatives of the public at large). Overall, 38% of physicians had a positive attitude toward guidelines viewed as a quality assurance tool for the medical profession. Overall, physicians seem to ignore that the need to rationalize health care calls for input from other professions and members of society. Indeed, most of the issues facing medicine today are mainly a matter of how much value our societies attach to the benefit expected from the available health services. The answers as to what should be done in health care probably cannot be left to the medical profession alone.

Adult↗

PubMed1990

Practice guidelines and standards: an overview.

Organized medicine, insurance companies, regulators, and the peer review organizations are all interested in practice guidelines. Recently, the U.S. Congress established the Agency for Health Care Policy and Research, which is charged with overseeing the development of practice guidelines. If properly developed, disseminated, and used, practice guidelines should reduce the incidence of inappropriate care and help control costs. Although guidelines have been used by physicians for years, guidelines now being developed should be more comprehensive, specific, exhaustive, and--on the basis of the best scientific evidence of effectiveness and expert opinion--more effectively discriminate between useful and useless care. Practice guidelines can improve the quality of care when used voluntarily by physicians in practice, when used as standards for quality monitoring and assurance programs, and when used as the basis for reimbursement for services. All interested parties should share responsibilities for the research, development, and production of appropriateness criteria, their translation into guidelines and standards, and the dissemination and maintenance of the guidelines, including evaluation, revision, and updating.

Clinical Protocols↗

PubMed2001

Implementing the revised American Psychiatric Association practice guideline for the treatment of patients with eating disorder.

Practice guidelines aspire to be authoritative statements regarding the state of the art in quality care for various clinical problems. The American Medical Association Partnership has set forth stringent parameters for guideline development by professional organizations, and these have been followed by the American Psychiatric Association in creating its practice guidelines for the treatment of patients with eating disorders. The revised edition, published in January 2000, benefitted from extensive input from a wide array of psychiatrists, psychologists, pediatricians, and other recognized experts who blended together available evidence-based practice with a considerable amount of clinical experience and consensus. These guidelines are useful for practitioners, students, and health-resource managers. Future research will continue to lead to constant upgrades.

Feeding and Eating Disorders↗

PubMed1997

Why use clinical pathways rather than practice guidelines?

BACKGROUND: Financial pressures from managed care organizations, the government, and other "stakeholders" have resulted in the production of practice guidelines and clinical pathways. Clinical pathways involve all segments of a health care system and may prove to be more beneficial and less hazardous to patients and health care providers. METHODS: A historical narrative describing the development of clinical pathways by the Southwestern Surgical Congress (SWSC) and the Southeastern Surgical Congress (SESC) is made. The motivations, the benefits, and the hazards of both clinical pathways and practice guidelines are discussed. RESULTS: Clinical pathways have proven to reduce length of stay (LOS), complications, and cost, and provide increased patient satisfaction whereas practice guidelines from some specialties show improved quality of care when compared with nonspecialists. However, many practice guidelines are developed by specialists on "best practice" standards, and few have documented studies proving their effectiveness. CONCLUSIONS: Eleven clinical pathways were developed by the SWSC and the SESC and are in the process of revision and study for efficacy. They will be disseminated in the American Surgeon and on the SWSC web site for review and comment. In 1998, both congresses hope to publish the efficacy of selected pathways by describing their effect on LOS and charge for those diagnostic-related groups.

Critical Pathways↗

PubMed1997

Computerized decision support based on a clinical practice guideline improves compliance with care standards.

PURPOSE: Clinical guidelines are designed to assist in the management of specific diseases; however, these guidelines are often neglected in the delivery of care. The purpose of this study was to determine whether clinician use of an clinical practice guideline would increase in response to having, at the patient visit, a decision support system based on a practice guideline that generates a customized management protocol for the individual patient using data from the patient's electronic medical record. SUBJECTS AND METHODS: In a 6-month controlled trial at a primary care clinic, 58 primary care clinicians were randomized to receive either a special encounter form with the computer-generated guideline recommendations or a standard encounter form. The effect of computer-generated advice on clinician behavior was measured as rate of compliance with guideline recommendations. Data from 30 clinicians were analyzed; data from 28 clinicians were excluded because these clinicians did not meet predefined criteria for minimum exposure to diabetic patient care. RESULTS: Availability of patient management recommendations generated by the decision support system resulted in a two-fold increase in clinician compliance with care guidelines for diabetes mellitus (P = 0.01). Median compliance for the group receiving the recommendations was 32.0% versus 15.6% for the control group. CONCLUSION: Decision support based on a clinical practice guideline is an effective tool for assisting clinicians in the management of diabetic patients. This decision support system provides a model for how a clinical practice guideline can be integrated into the care process by computer to assist clinicians in managing a specific disease through helping them comply with care standards. Use of decision support systems based on clinical practice guidelines could ultimately improve the quality of medical care.

Decision Making, Computer-Assisted↗