More than two years after a federal healthcare research agency released the first of its 12 clinical practice guidelines, physicians are slowly adopting the standards even as many fault them for their complexity and content.
Nobody seems to have firm information on how many physicians are using the guidelines written by the Agency for Health Care Policy and Research. But the agency and some of the pri- vate-sector groups that have worked with it say they have anecdotal evidence that physicians, providers and regulators are beginning to use them.
The agency is developing guidelines with the aim of helping physicians make better decisions and reduce ineffective and inappropriate services. Each guideline costs $650,000 to develop.
But some physicians and provider groups argue that the agency's guidelines do not fit within practices or healthcare delivery systems, are too cumbersome and often are based on experts' consensus and literature reviews rather than original research.
These are issues that the agency, part of the federal Public Health Service, was considering as it released its 13th such guideline last week. That guideline is aimed at improving the quality of mammography.
"The best guideline is one written within a delivery system, where implementation of a guideline fits within the way a system works," said Douglas Wood, M.D., a cardiologist who is vice chairman of the department of medicine and chairman of the practice analysis group at the Mayo Clinic in Rochester, Minn.
"With AHCPR, you don't really talk about how you're going to implement (the guidelines). They're just out there," Dr. Wood said.
AHCPR spokesman Bob Isquith responded, "We say adapt the guidelines, not adopt."
Agency officials said the very first guideline, which was released in March 1992 and recommends more aggressive treatment of pain in surgical patients, is the one most frequently used. In fact, California in 1993 passed a law that sought to distribute information about the acute pain guideline to physicians.
Other guidelines are finding wider use in long-term-care facilities. Maryland, for instance, has adopted a long-term-care policy that could tie state reimbursement to use of the agency's urinary incontinence treatment guideline.
And Minnesota, in its MinnesotaCare Act of 1992, cites adherence to the agency's guidelines as a defense against malpractice.
But other institutions have been slower to adopt the federal guidelines. Managed-care plans often have drafted their own practice protocols because they saw the agency's guidelines as being too oriented to acute care, not primary care, said Diane Alexander Meyer, associate director for medical affairs at the Group Health Association of America.
The mammography guideline would have been useful to HMOs had it been released earlier, Ms. Meyer said. But many HMOs already have written their own mammogram guidelines, she said.
But Ms. Meyer also said that managed-care plans now believe the agency's guideline development is evolving. "AHCPR is listening, and they're tackling subject areas that are more important to HMOs," she said.
Christel Mottur-Pilson, who as executive director of the Internal Medicine Center to Advance Research and Education has tested drafts of some of the guidelines with physicians, said the agency also needs to do a better job of simplifying its guidelines so doctors can understand them quickly and put them into practice.
"If a guideline is overly long, the guideline faces an uphill battle," she said.