Class 5

Evidence based Medicine or Medical Guidelines or Critical Pathways or Care Maps

Evidence-Based Medicine:

  • To practice evidence-based medicine, physicians must combine study results with own clinical judgment and patient preferences – hoped for outcome is significantly improved quality of care.
  • Conscientious, explicit, and judicious use of current best evidence in making decisions about care of individual patients.
  • Physicians are more likely to be sued for not following guidelines than for abiding by them.

Evidence-based medicine is the “conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” and “to practice evidence-based medicine, physicians must combine study results with his/her own clinical judgment and patient preferences.  The hoped-for outcome is significantly improved quality of care.”

Some physicians resent this approach and in the past called it “cookbook” guidelines, and strongly claimed that there were too many individually controlling factors to systemize medical care.

Most clinical protocols originate with specialty societies or expert panels and not with HMOs.  According to the AMA, 90 or so organizations have promulgated approximately 2,000 guidelines.

In theory, physicians who can document that he/she’s followed a guideline developed by a respected organization should have a pretty solid defense in a medical malpractice lawsuit.  However, there is a lot of controversy over this theory among physicians and attorneys.

A dozen cases were studied where guidelines were considered important and found that in those lawsuits, physicians were more likely to be sued for not following the guidelines than for abiding by them.

If it can be shown that a physician deviated from a medical guideline that makes the Plaintiff’s argument more effective that the physician fell below the standard of care and vice versa. If it can be shown that the physician complied with the standard of care it tends to work in their favor.

Many physicians still believe that it is better to order tests to negate the possibility of something in case a patient with a bad result seeks out an attorney, as according to one physician, it is a “fact of life” you rarely “get sued for doing too much.  You get nailed for doing too little.”

In 1991, Maine started a pilot project to let physicians use certain practice parameters to defend themselves in court and about 400 physicians in four specialties volunteered for the experiment.  Eight years later, not a single lawsuit had been filed against a physician where the guidelines were a critical issue. Medical leaders and the Clinton administration wanted to duplicate this project around the country.  Similar experiments were either abandoned or repealed in Florida, Minnesota, and Vermont.

There is substantial consensus that quality can be measured in some important areas of health care.  He claims that there is little disagreement that the effectiveness of care in bringing about desired outcomes is an important aspect of quality.  For example, survival rates for elective surgery, if properly adjusted for patient risk, have high face validity as a measure of hospital and surgeon performance.

Studies have shown that in general, patients rank quality information far behind convenience, coverage, access, and cost in choosing health plans

Studies have shown that in general, patients rank quality information far behind convenience, coverage, access, and cost in choosing health plans.  Also, consumers value information on health choices from friends, family and personal physicians much more than information from government sources.

This editorial concludes that unless purchasers actively support not only “promoting but also visibly using performance measures, the market effect of performance data will be very small indeed.  In that case, the pressure will increase for regulations and laws to reward or punish health care provider organizations and health plans on the basis of performance measures.”

Experience over the past ten years indicates that developing sound, evidence-based guidelines is not enough to improve the quality of health care, that careful attention to both knowledge-based factors and organizational factors in the implementation process will maximize the likelihood that “guidelines fulfill their promise in improving patient care.”  Health care researchers can improve the evidence base for guidelines prior to dissemination and increase understanding of organizational variables and social influence strategies that promote successful implementation.

A disadvantage of Critical pathways or care maps is when a patient falls out of the standard pathway – variances should be documented accordingly

Critical Pathways or Care Maps attempt to plot out the day to day process of healthcare delivery for a standard patient admitted with a specific diagnosis. Predominantly sponsored by nursing as an adjunct to the nursing care plan and physicians to foster timely and appropriate utilization and reduce variations in care. Major advantage is to present an organized structure and process for healthcare delivery. Suggestions might be made as to when to transfer a patient to a lower level of care, or the best timing for repeat testing or diagnostics. Many institutions using critical pathways have shown improvements in length of stay and total charges of twenty percent (20%) or more. A disadvantage of Critical pathways or care maps is that when a patient falls out of the standard pathway, variances should be documented accordingly.

Experience over the past ten years indicates that developing sound, evidence-based guidelines is not enough to improve quality of health care, that careful attention to both knowledge-based factors and organizational factors in the implementation process will maximize likelihood that guidelines improve patient care

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