I think this article brings up a lot of issues we've been discussing in class, especially in relation to the chapters we read in Wennberg, and particularly thinking about what to do when evidence-based guidelines don't conform with performance measures, using the exampe of VTE prophylaxis. It is interesting that one of the authors' first points is that national performance measures should be based on scientific evidence. Obviously, this makes sense, especially given our conversations on evidence-based medicine, but I think this leads to questioning why performance measures aren't based (at least generally or in a majority of situation) on scientific evidence. We've spoken to some degree about preference-sensitive care and provider practice patterns, but it doesn't seem as though these categories necessarily have to have a negative impact on the quality of care. I guess I'm thinking that, depending on the condition studied, national performance measures might not be useful. For instance, national performance measures wouldn't be useful if response to treatment varied by geographic region or by ethnicity; in this case, it seems as though national performance measures should only be instituted where a national sample had a homogenous response to a test or treatment, which is why it would be important to examine whether benefits and risks are homogenous, as the authors state. However, for conditions that did not show homogenous responses, would there then be community-based performance measures, or performance measures based on some other variable, or no performance measures for that condition at all?
This article addresses many of the concerns that providers have regarding guideline-based medical care. The first point, that the guidelines are based on evidence based medicine, is quite a challenge. Much of the practice of medicine is based on 'what we have always done' or 'I remember a case that was like this' but does not create consistency among a population. One can argue that a population is also not truly homogenous and it would be impossible to generalize guidelines sufficiently to cover all possibilities for 'individualized health care.' The authors present a very good argument for this, such as the use of antibiotics within 4-8 hours of presentation with pneumonia. Many times, practioners struggle with using a therapy when doing nothing, or waiting for clinical symptoms to present, may be better for the patient. This guideline was likely not based on the best evidence that could be generalized to an entire population.
To address these concerns, more flexible algorithms have been created to work through the 'what if' of an individual's situation. This, I believe, has been the most effective use of guidelines to standardize medical care. The authors make this their third and fourth point, which allows clinicicans to stray from the hard and fast rules of guidelines (with good documentation and reasoning) and to work within decision trees to assess the appropriate diagnostics or therapies available.
Overall, this article addresses many of the concerns I have heard voiced regarding guidelines while also exhibits an appreciation for individualized medical care.
I think this article brings up a lot of issues we've been discussing in class, especially in relation to the chapters we read in Wennberg, and particularly thinking about what to do when evidence-based guidelines don't conform with performance measures, using the exampe of VTE prophylaxis. It is interesting that one of the authors' first points is that national performance measures should be based on scientific evidence. Obviously, this makes sense, especially given our conversations on evidence-based medicine, but I think this leads to questioning why performance measures aren't based (at least generally or in a majority of situation) on scientific evidence. We've spoken to some degree about preference-sensitive care and provider practice patterns, but it doesn't seem as though these categories necessarily have to have a negative impact on the quality of care. I guess I'm thinking that, depending on the condition studied, national performance measures might not be useful. For instance, national performance measures wouldn't be useful if response to treatment varied by geographic region or by ethnicity; in this case, it seems as though national performance measures should only be instituted where a national sample had a homogenous response to a test or treatment, which is why it would be important to examine whether benefits and risks are homogenous, as the authors state. However, for conditions that did not show homogenous responses, would there then be community-based performance measures, or performance measures based on some other variable, or no performance measures for that condition at all?
ReplyDeleteThis article addresses many of the concerns that providers have regarding guideline-based medical care. The first point, that the guidelines are based on evidence based medicine, is quite a challenge. Much of the practice of medicine is based on 'what we have always done' or 'I remember a case that was like this' but does not create consistency among a population. One can argue that a population is also not truly homogenous and it would be impossible to generalize guidelines sufficiently to cover all possibilities for 'individualized health care.' The authors present a very good argument for this, such as the use of antibiotics within 4-8 hours of presentation with pneumonia. Many times, practioners struggle with using a therapy when doing nothing, or waiting for clinical symptoms to present, may be better for the patient. This guideline was likely not based on the best evidence that could be generalized to an entire population.
ReplyDeleteTo address these concerns, more flexible algorithms have been created to work through the 'what if' of an individual's situation. This, I believe, has been the most effective use of guidelines to standardize medical care. The authors make this their third and fourth point, which allows clinicicans to stray from the hard and fast rules of guidelines (with good documentation and reasoning) and to work within decision trees to assess the appropriate diagnostics or therapies available.
Overall, this article addresses many of the concerns I have heard voiced regarding guidelines while also exhibits an appreciation for individualized medical care.