Test practice guidelines and pathways
Evaluate outcomes often to screen QI barriers
By Elgin K. Kennedy, MD
Editor, The Assertive Utilization and Quality Report
The purpose of practice guidelines, clinical pathways, and other protocols is to change the way patients are cared for. The hope is that the use of evidence-based guidelines will provide more informed decision-making, reduce variation, and improve the quality of care.1
Simply installing a national evidence-based guideline does not, however, automatically guarantee better care. Some major barriers block quality improvement:
• The guideline may be ignored by those who feel their clinical autonomy is threatened, those who argue that guidelines devalue the art of medicine, or those who feel that guidelines are just a fad in health care management.
• The guideline may be so narrow in scope that it is applicable to few patients.
• The guideline may have been changed to fit local needs, and as a result, there may be less certainty of its effectiveness as a quality improvement endeavor.
• The guideline may be misapplied due to problems of clarity or interpretation.
• The guideline may not fit the clinical situations present at your organization it may not be portable from one organization to another.
• The guideline may cause unexpected and undesirable effects. For example, a study showed limiting the free drugs available to Medicaid patients led to worsened health and significant increases in their other health care expenses.2
• Organizational inefficiencies may impede the effectiveness of a guideline. For example, a slow turnaround time for a new lab test may actually produce worsened outcomes compared to not using the guideline and lab test.
Any change in patient care, whether it is the introduction of a new drug, a new technology, or a new guideline, is associated with potential benefits, risks, and costs. The federal Food and Drug Administration requires safety and efficacy data before releasing new drugs. The agency requires Phase 4 drug studies even after drugs are released to discover unexpected serious adverse effects.
You should periodically evaluate the outcomes of each practice guideline and critical pathway at your organization. Some may harm patient care and increase your costs.
[Editor’s note: The preceding article was first published in the September 1997 issue of The Assertive Utilization and Quality Report $60 per year (12 issues). For more information, contact Elgin Kennedy, MD, 204 Second Ave., No. 334, San Mateo, CA 94401. Telephone: (415) 348-3647.]
Reference
1. Weingarten S. Practice guidelines and prediction rules should be tested after implementation (editorial). JAMA 1997; 227:1997-1998.
2. Soumerai SB, et al. Effects of Medicaid drug-payment limits on admissions to hospitals and nursing homes. N Engl J Med 1991; 325:1072-1077.
Suggested reading
Berger JT, Rosner F. The ethics of practice guidelines. Arch Intern Med 1996; 156:2051-2056.
Vladeck BC. Managed care and quality. JAMA 1995; 273:1483.
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