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Does clinical guideline adherence mean quality care?

By Tom Dahlborg posted 07-19-2011 11:38

  
(originally published at www.hospitalimpact.org)

I hear often from healthcare leaders that they want to deliver the "right care at the right time at the right cost." They also share their desire for consistency and predictability, and often point to the development of clinical guidelines as key to achieving all of those goals.

As a healthcare leader, and with the above goals in mind, I ask you to consider the following scenario.

Imagine managing a significant but not debilitating health challenge and needing professional help. Take a moment to visualize not knowing where to turn or what to do next.

Over time you learn that you can go online to a website and see which medical school a physician has attended, whether the physician is licensed in your state, and their specialty.

Your friends have told you about another site where you can assess the quality of physicians and see the number of blue ribbons they have received.

You follow your friends' recommendations. You identify a physician who is clearly an expert in her field. She is licensed and certified in your state. She graduated from one of the best medical schools in the country and has received a number of blue ribbons for clinical guideline adherence.

You make your selection, comforted by these data. You will be in good hands.

You visit this new physician and within 12 minutes you have your diagnosis and are off to pick up your prescription (as per the clinical guidelines).

While at the pharmacy waiting for your prescription you access your new iPad. You Google your new diagnosis and in so doing begin to follow a variety of interesting links.

You find an interview with Shannon Brownlee (author of Overtreated) and read, "But an enormous amount of medicine is not based in science. In fact, the Institute of Medicine estimates that maybe half of what physicians do has valid evidence to back it up."

Intrigued, you continue your search and see that according to a study published in the Archives of Internal Medicine and referenced by Douglas Perednia, MD, in a recent blog post, "only 14 percent of the 4,218 individual recommendations (from 41 clinical guidelines) released by the Infectious Diseases Society of America between 1994 and 2010 were based upon properly randomized controlled trials."

Then you come across "The Truth Wears Off" article about the "decline effect" and its application to clinical research outcomes, and you begin to further understand the challenges of empiricism.

Processing all of this information, you refer back to the blue ribbons awarded to your new physician for clinical guideline adherence and hope that the guidelines she (and now you) are following were derived from research that IS considered trustworthy, from PROPERLY randomized controlled trials, in which the decline effect has NOT been shown to be at play.

You wonder how even the best of the best clinical guidelines, which are resultant from the trustworthy research and properly randomized controlled trials, can be effective for each and every patient. You ask, "Are all diabetic patients the same? Are all patients with high blood pressure the same? Am I the same as every other patient with my same diagnosis?"

You consider your own situation. One of your grandparents and two of your cousins have received the same diagnosis as you. You have two children in college and are taking care of your elderly mother while working full-time. Your allergies are working overtime and your gut is just not quite right.

You wonder if a 12 minute office visit with your new physician truly positioned you both to account for all of these variables. Were all of these data points best leveraged in planning your specific course of treatment?

You further contemplate whether the clinical guidelines recommended by your physician are really appropriate for you. Or worse, could they be harmful?

You begin to imagine an improved model of healthcare that would better meet your needs as a patient, the needs of your family, and the needs of your community.

With your patient hat on, what does it look like?

Now, put your healthcare leader hat back on and please ponder the following questions:

  • Are your goals as a patient congruent with your goals as a healthcare leader? Should they be?
  • Is "right care at the right time at the right cost" the same for everyone? Should it be?
  • Is strict adherence to clinical guidelines to be awarded? Even if the clinical research leveraged to create the specific guidelines is potentially questionable?
  • Is strict adherence to clinical guidelines to be rewarded? Even if we are each a complex adaptive system with thousands of variables at work at any one time?
  • Is your healthcare organization honoring all aspects of the Hippocratic Oath (e.g., "I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability")?

Now, with your health leader hat still on, imagine an improved model of healthcare that would better meet your needs as a healthcare leader AND your needs as a patient.

What does this new model of healthcare look like?

What one specific thing can you do today to move your organization closer to this new model?

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Tom Dahlborg
07-21-2011 09:19

Dear Dawn - Thank you for your comment and sharing.
One concern is the definition of "Evidence Based Medicine". As another reader noted "the question becomes 'Who's evidence?'"
Practice guidelines and standards of care change frequently based on the latest publications in NEJM, JAMA, Health Affairs, or Lancet. The "evidence" changes rightly or wrongly and then the new information may or may not trickle down to the physician and the patient.
Add to this information such as Dr. John Ioannidis' findings that 80 percent of non-randomized studies turn out to be wrong, as do 25 percent of supposedly gold-standard randomized trials, and as much as 10 percent of the platinum-standard large randomized trials, and yet they are still the standard of care in many cases.
In the current healthcare model a typical primary care physician is obligated to generate X number of RVU's per day, may be triple booked every 15, and does not have the time to thorougly read and comprehend the latest research nor develop authentic relationship and trust with their patients.
At a minimum (and as a start) I would propose we focus on ensuring the following elements of a new healthcare paradigm are in place:
1. Physicians must have easy access to unbiased clinical research experts (or if it is understood that there will always be some bias then we ensure that the bias is well documented and understood)
2. Physicians must be educated on how best to critically review, assess, and analyze the clinical research for themselves
3. Physicians must have the time to invest in assessing the latest research
4. Physicians must have the time and space to discuss the research data and resulting varied treatment options with trusted colleagues
5. Physicians must have the opportunity to leverage the now understood clinical research and discuss a challenging patient situation and/or a "best practice" in a safe setting with trusted colleagues
6. Physicians and patients must have the time and space to develop real relationships and trust where information flows freely
7. Physicians and patients must have the time and space to get to the root-cause of a symptom and co-create a treatment plan that is based on accessible, valid, understood, unbiased (or understood bias) and trusted clinical research outcomes and which is best suited for the specific patient
8. Outcome goals and metrics for each specific patient must be developed together by the physician and patient, assessed regularly, and the treatment approach modified as appropriate (using a PDCA, or plan/do/check/act type approach), and again leveraging the now understood and trusted clinical research
9. Physicians must be compensated appropriately for all the above
The current system does not allow for these key factors to be in place to ensure the latest and best information is available and understood by both physician and patient and leveraged to best position the patient to achieve their individual health goal.
I believe we can do better and expect with better understanding of the data and the above implemented we will not only better positions patients and improve health outcomes, we will also improve physician job satisfaction, retention, recruitment (based on what physicians have shared), and bend the medical cost curve.
Thank you again for sharing.
Tom

Dawn Bynum
07-20-2011 07:38

Well, what can I say....
I certainly do not have an action plan to "create a new model".
I can say that dissent is good but that patients should be encouraged to get their information from trusted sources, which should be provided to them. (uptodate, for example).
Reading about medical mistakes in the hospital and the outpatient setting, including decisions which are not evidence based puts the patient in a unique position...most are not medically trained enough to understand the full meaning of these articles nor to read clinical trials and completely understand their results. They are left knowing that there is a problem and having only their physician (and perhaps a second opinion) to address their concerns.
Finally, if a patient cannot rely on another human being, who is trained for 8+ years to care for them medically, what is the world to do about it? If quality measures are based on evidence based practice, is that not enough?