President's Message

Practice Guidelines

N.H. Tucker, III, M.D., President

In the hierarchy of practice parameters, practice guidelines fall between standards and practice options. Standards are almost universally accepted principles of patient management and are the "gold standard." Next in the pecking order are the practice guidelines defined by the Institute of Medicine as "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances." They are recommendations for patient management. Lastly, practice options are practice policies without wellknown outcomes and in which preferences are unknown or divided.

There are several forces driving the development of practice guidelines. Some think the major impetus is that of managed care for cost containment. However, there is some argument that practice guidelines can actually increase the cost of health care by recommending that more, not less, be done. Another driving force is the quest to sculpt medical practice based on scientifically based outcomes (Evidence-based Medicine) rather than on opinions. To help with this, more and better research information on outcomes measurements are available than ever before. Another force is the desire to reduce wide and often unexplainable practice variations. Also, liability insurers are developing guidelines that they hope will reduce professional liability risk. Lastly, there is a trend to include patients as well-informed partners in their personal health care decisions.

As stated earlier, practice guidelines are becoming ubiquitous. They are being developed by managed care organizations, hospitals (often under the name clinical pathways), government agencies (such as AHCA here in Florida and the Federal Agency for Health Care Policy and Research [AHCPR] ), and by many different medical organizations including the AMA and some of our national and state subspecialty societies. Dissemination of the available guidelines (over 1,800 as of 1994) is difficult. The AMA "Directory of Practice Parameters" is regularly updated and is a good reference source. The National Institute of Health has a web site of the guidelines they have developed (http://text.nlm.nih.gov).

Practice guidelines should be scientifically based, clinically relevant, and applicable in the day to day practice of medicine. It is felt that whenever scientific outcomes data is available that this data is the best foundation for a good practice guideline (evidence-based). When this outcomes data does not exist, then good clinical judgement is the next best option to base the guideline on. As the saying goes "If you don't have good clinical evidence, then use good clinical judgement."

The AMA has developed a set of attributes for developing practice parameters. These attributes are:

1. Practice parameters should be developed by or in conjunction with physician organizations;
2. Reliable methodologies that integrate relevant research findings and appreciate clinical expertise should be used to develop practice parameters;
3. Practice parameters should be as comprehensive and specific as possible;
4. Practice parameters should be based on current information; and
5. Practice parameters should be widely disseminated.

Practice guidelines are as good or as bad as the entity and/or individuals/physicians that develop them. A bad guideline can negatively impact patient care and might even increase professional liability exposure. On the other hand, a good guideline can be very beneficial in helping the physician in his clinical decision making (not to mention the assistance that this guideline might give our patients in their decisions). This good guideline can improve the quality and effectiveness of the medicine we practice. Only if dedicated physicians give of their time and talent to develop the finest guidelines that can be developed, can we be assured that we have acceptable quality guidelines for the future.

REFERENCES

1. Roberts RG, Rosof BM, et al. Practice Guidelines: Coping with information overload. Patient Care. 2/29/96; 39-57.
2. American Medical Association: Attributes to Guide the Development of Practice Parameters. American Medical Association/Specialty Society Practice Parameters Partnership, reprint 1994.

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