“In an age of mandated cost control and resource limitation under managed care,” the researchers wrote, some physicians still regard practice guidelines as “cookbook medicine” that threatens the use of clinical judgment and encourages treating patients as essentially interchangeable. In the face of that perceived threat, the researchers added, many physicians continue to uphold a traditional view of medicine as an art “in which individual expertise and technique are allowed to shine through and ultimately result in a higher standard of patient care.”
Dr. Corrigan acknowledges the significant obstacles to successful practice guideline implementation:
- Guidelines are developed by various sources, particularly specialty societies, who do not always coordinate their activities. Physicians are left with overlapping and sometimes contradictory guidelines for managing the same disease or condition.
- Guidelines must be maintained and kept current, or physicians will lose confidence and not follow them.
- Guidelines are of varying quality. Some provide clear clinical direction; others are not written in a way that physicians can clearly translate into clinical practice.
- There are significant gaps in the evidence basis for guideline development. Much more comparative effectiveness research needs to be conducted to develop more valid and meaningful guidelines.
- Guidelines must be communicated effectively to physicians, making them available and convenient at the point of clinical care. Electronic health records with user-friendly decision support functions show great promise in “making the right thing the easy thing to do.”
- The fee-for-service payment system encourages greater volume of services, irrespective of guideline recommendations.
Physicians also recognize inherent limitations of guidelines. “Guidelines typically apply across populations. Adding levels of clinical complexity gets further away from a guideline’s applicability. Many physicians will tell you that the patient in front of them is a special case requiring a modification of the protocol,” Dr. Boutwell explains. For example, diabetic management guidelines are based on what is best for a population of diabetics, versus what is best for said hospitalist’s patient who has eight co-morbidities, one of which is diabetes, Boutwell notes. “Guidelines come disease-specific. Patients don’t,” she adds.
Nevertheless, Dr. Boutwell notes, there are robust guidelines and the IHI tries to help front-line physicians and care teams to implement them reliably and effectively.
An obstacle that inhibits hospitalists from implementing guidelines in an optimal fashion “is that we’re not one specialty—we deal with it all—and that complexity can be overwhelming. There is no central repository where all of the guidelines can be found in one place,” according to William T. Ford, MD, FHM, program medical director for Cogent Healthcare and section chief of hospital medicine for Temple University Hospital in Philadelphia.
Make Guidelines Work
Researchers say guidelines are most successful when they are well-supported and uncomplicated, backed by strong leadership and sufficient resources, and are used as “rallying points” to stimulate interdependent and collaborative care among physicians, nurses, pharmacists, equipment suppliers, administrators, and patients.
“Guidelines are really the foundation for determining best practices,” Dr. Torcson says. “There is no shortage of excellent guidelines, or proof that specific interventions do improve outcomes. The key is achieving more uniform implementation. We need tools like pre-printed orders in electronic health records (EHR) to effectively integrate these guidelines into hospitalists’ practice.”
More widespread EHR adoption with user-friendly medical decision-support systems will play a huge role in boosting guideline adoption and effectiveness, says Mary Nix, MS, MT(ASCP)SBB, health science administrator at AHRQ and project officer for the agency’s Center for Outcomes and Evidence.
Dr. Ford says HM groups must evaluate the top 10 to 15 diagnosis-related groups (DRGs) that they see each day (e.g., congestive heart failure, acute kidney failure, pneumonia, cellulitis, or acute coronary syndrome) and come to consensus on which guidelines best address them.