Does Algorithm-Guided Care Have an Adverse Effect on House Staff Knowledge?
January 1, 2001 3 minutes read
Does Algorithm-Guided Care Have an Adverse Effect on House Staff Knowledge?
Abstract & Commentary
Synopsis: Use of a respiratory therapy consult service in which respiratory therapists determine patients’ respiratory care plans based on algorithms did not affect house officer’s expertise in respiratory care management.
Source: Stoller JK, et al. Respir Care 2000;45:945-952.
Respiratory therapy "evaluate and implement" protocols have been advocated as a means of increasing the appropriateness of respiratory care prescribing, while decreasing costs and averting morbidity. Although studies indicate that explicit algorithms and/or care plan guidelines positively impact the use of respiratory care services (RTCS), concern has been expressed that the use of such protocols may negatively impact medical trainees’ education.
To determine if a RTCS detracted from internal medicine house officers’ knowledge of respiratory care ordering, Stoller and colleagues tested trainees in two academic teaching hospitals, one with and one without a RTCS. Each trainee was asked to review five case studies consisting of a brief clinical vignette accompanied by four multiple choice questions about the type of respiratory care treatment indicated. To avoid institutional bias, cases were prepared by practitioners at both institutions. The case studies were distributed at a scheduled meeting of internal medicine house staff after a verbal explanation of the study. Of those eligible, 57 (33%) completed the case studies, including 25 interns, 17 junior residents, and 15 senior residents. There was no difference in the overall scores for trainees where a RTCS was used or was not used, 77.2% ± 11.6% vs. 75.8% ± 12.0%, respectively (P = 0.69). Between group comparisons of answers on each case study showed a significant difference for one case study. House officers at the institution with a RTCS achieved a higher score (86.6% ± 18% vs 69.1% ± 14%, P = 0001), a difference that persisted after adjusting for year of postgraduate training.
Comment by Leslie A. Hoffman, PhD, RN
The main finding of this study was that internal medicine house officers’ knowledge of respiratory care ordering, as assessed by responses to case studies, was similar among trainees at a teaching hospital in which use of respiratory care protocols was longstanding and trainees at a teaching hospital where such protocols were not in use. The overall rate of correct responses was similar and there was no indication that house officer’s years of postgraduate training confounded the results.
Although the use of various types of guidelines (algorithms, protocols, care pathways) holds great promise, their ultimate value is determined by the effect they have on patient care, including their effect on the quality of care, patient satisfaction, and costs. Over the past 10 years many studies have evaluated the effect of guidelines on patient care. In a recent review, 55 of 59 guideline studies demonstrated at least one beneficial change in the process of care and nine of 11 studies that examined patient outcomes showed improved care.1 Thus, published evidence strongly supports the assertion that guidelines can improve care. Nevertheless, many clinicians resist using this approach.
In this paper, Stoller et al address a specific concern with the use of guidelines—they may detract of the education and experience of house officers in academic teaching institutions. Their study’s findings demonstrated no discernable effect. As acknowledged by Stoller et al, there are several limitations to this study. Only two institutions were involved. Responses were elicited from only a minority (33%) of house officers and there is no way to determine impact at the bedside. Subject to these interpretive cautions, findings of this study provide initial support for the premise that use of a RTCS does not affect house officer knowledge and strengthens the rationale for use of such protocols.
Reference
1. Weingarten S. Chest 2000;118:4S-7S.
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