Two reports issued last week by the Institute of Medicine provide standards for formulating clinical practice guidelines and reviewing the scientific papers and clinical trials that underpin the guidelines. The challenge for physicians and clinical executives will be to adopt standards that reduce variation in care without losing sight of the art of medicine, according to one physician executive.
Hold onto 'art of medicine'
IOM urges standards for clinical guidelines
The art side of medicine is what can help practitioners following the science to still meet one of the six aims of the national quality strategy that HHS released last week—ensuring person- and family-centered care.
Congress directed the IOM to conduct and report on both studies in the Medicare Improvements for Patients and Providers Act of 2008, according to the IOM. The reports, Finding What Works in Health Care: Standards for Systematic Reviews and Clinical Practice Guidelines We Can Trust, are an attempt to ensure a standard, methodical approach to integrating new research into clinical practice and ensuring that conflicts of interest don't affect that approach, said Dr. John Spertus, director of cardiovascular education and outcomes research at St. Luke's Mid America Heart and Vascular Institute, part of St. Luke's Health System, Kansas City, Mo.
The conflicts, such as when physicians who strongly favor a certain treatment or have commercial relationships that would benefit from a treatment's endorsement as a practice guideline are involved in making those decisions, are not always recognized as a problem, Spertus said.
The report on practice guidelines is more directly applicable to hospital-based physician executives, but the systematic review standards may help convince holdouts who still think of evidence-based guidelines as “cookbook medicine,” said Dr. Lee Norman, senior vice president and chief medical officer of the University of Kansas Hospital, Kansas City, Kan. “These standards will help give caregivers more comfort knowing that there's scientific rigor behind the derivation of these guidelines,” he said.
Physician executives will have to look at three steps to make these reports pay off, Norman said—adapting guidelines to their facility, ensuring they are being used in practice and monitoring compliance and outcomes. Another question is how often guidelines will be updated, he said.
The reports are well thought out, said Dr. Paul Sternberg, assistant vice chancellor for adult health affairs at Vanderbilt University Medical Center, Nashville. “I think that it's not going to create any undue hardship for those involved in creating practice guidelines.” Vanderbilt Medical Group has a team that works on formulating clinical practice guidelines and evaluating those published by other organizations, producing about eight to 10 “clinical pathways” annually, Sternberg said.
Physicians and physician executives, especially if bundled payment use increases, must balance compliance with evidence-based medicine with the art of medicine, Sternberg said. “A certain amount of variation is acceptable, and you're going to want that,” he said. “Gross variation is not acceptable. Where is the sweet spot? That's going to be the challenge.”
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