Practice guidelines: best hope for quality improvement in the 1990s

Article Abstract:

In the 1990s, the importance of quality in medical care will assume a central role, forcing concern over health care costs to move a bit to the sidelines. Practice guidelines (guidelines for medical practice) are central to quality improvement and control; issues relevant to this topic are reviewed and evaluated. This represents one contribution to a series of articles in the December 1990 issue of the Journal of Occupational Medicine; the series presents different viewpoints concerning occupational physicians' changing roles in health resource management. The development of practice guidelines was encouraged by several public agencies in 1988, motivated, at least in part, by the general feeling that the value of health care may not justify its exorbitant cost. Practice guidelines spell out what should be done, or avoided, in defined clinical situations. They may be general (''patients with symptom X should be evaluated for appendicitis'') or specific (''patients with symptom X should undergo physical examination to screen for signs A, B, or C''). The concepts of service overuse, underuse, and misuse are defined and discussed. Development of practice guidelines is based on the review of clinical research data with the contribution of expert clinical opinion. Research data must be appropriately evaluated, a difficult task since little clinical research has been carried out with scientific rigor. Thus, determination of the appropriateness of procedures is particularly difficult: this is illustrated with an example. The Clinical Efficacy Assessment Project, one attempt to generate guidelines, is evaluated. Problems with existing guidelines, most of which have not been scientifically formulated, are considered. When developed, guidelines can be used in education and research, as well as for reimbursement and quality improvement. Physician acceptance is, of course, critical, and the issue of liability must be addressed. Guidelines are here to stay, and physicians should participate actively in their development. In this manner, they will be able to ensure maximal control over medical practice. (Consumer Summary produced by Reliance Medical Information, Inc.)

Usage, Clinical medicine

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Why doctors do what they do: determinants of physician behavior

Article Abstract:

Although physicians receive only about one-fifth of the health care dollar in direct fee payments, the decisions they make cause at least four-fifths of all health care expenditures. Thus, physician decision-making is a critically important process in the economy of health care. Some models of this process are evaluated, with an explanation of the economic view of the physician's role in the US marketplace. Physicians are rarely trained in cost/benefit analysis, and usually do not know the prices of the tests they order. The effects of changing the supply of physicians and hospitals are discussed, as are incentives and controls that affect physicians' treatment decisions. Do physicians induce demand for services, or do they simply acquiesce to trends that are already in motion? The answer has important implications for the economy. Consequences of different aspects of physician activities are evaluated, including physicians' use of technology, their role as patient advocates, appropriate versus inappropriate treatments they administer, and use-overuse issues. Attempts to change physicians' behavior have had varying degrees of success: malpractice reform, for instance, does not seem to have much of an impact. Similarly, peer review, physician education and feedback, and practice guidelines cannot be said to have been particularly worthwhile. Local peer pressure and local norms, though, have considerable power to influence physicians. Group practice decisions are contrasted with decisions made by individual physicians: in general, decisions made by groups are more accurate. In summary, changing physicians' health care behaviors will be achieved by using many approaches that reinforce and support each other, with the instilling of constant awareness that change is mandatory. Otherwise, behavior is likely to revert and result in delivering a lower quality of care. (Consumer Summary produced by Reliance Medical Information, Inc.)

Management, Medical care, Cost of, Health care costs

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The bridge from quality assurance to quality improvement

Article Abstract:

Corporations, when faced with intense competitive pressures, typically respond by increasing the value of their product relative to its price. This has not occurred in the case of medical care purchased through employee benefits programs, however. Limiting services considered medically unnecessary does not improve the efficiency of services unless quality is also improved. A series of articles in the December 1990 issue of the Journal of Occupational Medicine presents different viewpoints concerning changing conditions in employee health care management. Quality improvement (QI) builds on quality assurance (QA), aiming to use QA data to identify problems. QI then does the following: tries to solve these problems in the best way; uses input from patients and payers; uses resources from all members of the health care team; promotes the involvement of all care providers; reduces the need for inspectors; and leaves itself open to redefinition in light of new outcome data. Medicine, through QI, can change in ways mandated by its practitioners. Therefore, practitioners should take the concept of quality improvement very seriously. (Consumer Summary produced by Reliance Medical Information, Inc.)

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