No standards in US "healthcare"

Is US "healthcare" really Russian Roulette?

From Medscape Money & Medicine
U.S. Medical Care Still Far From Standardized
Christine Wiebe [Medscape Money & Medicine, 2001. 2001 Medscape, Inc.]

Despite the prevalence of established clinical guidelines, many physicians are still reluctant to follow them, citing concerns about cost cutting or oversimplification. Some fear that variations in outcomes will not be reduced until guidelines get more widespread use.

  Most patients expect to receive the latest and best treatments when they visit a doctor. After all, a huge body of medical research has produced significant evidence and consensus about the best way to manage a variety of diseases and conditions.

  But do most doctors follow established standards, or are they even aware of them?

  "Variation of care is very prevalent," said George Isham, MD, chief health officer for Health Partners in Minnesota ( When that health plan looked at how member doctors treated bladder infections, for example, they found about 80 different approaches, he said.

  "Medicine is still very much a cottage industry," Dr. Isham said.

  The field of evidence-based medicine is trying to change that, producing clinical practice guidelines that give health care practitioners a way to implement the latest research findings. Some managed care organizations and health care systems have tried to promote the use of practice guidelines and thus reduce the amount of variation in patient care.

  But many barriers remain. Some physicians are philosophically opposed to what they consider "cookbook medicine," and many are either unaware of or simply unable to digest the hundreds of guidelines available for treating a myriad of conditions.

  "Most physicians still fall back on their experience and use textbooks or ask a colleague, rather than pulling out a guideline to see, 'What should I do?'" said Terrence Shaneyfelt, MD, MPH, chief of general medicine at the Birmingham, Ala., VA Medical Center.

Guideline Clearinghouse Usage Growing

  In order to organize the hundreds of available clinical practice guidelines and make them more accessible to the health care community, the federal government created the National Guideline Clearinghouse (NGC). The website is maintained by the Agency for Healthcare Research and Quality, and is cosponsored by the American Medical Association and the American Association of Health Plans (AAHP).

  The website currently receives about 38,000 visits a week, said Jean Slutsky, project officer, defining a visit as a series of consecutive inquiries on the site. Potential users are basically anyone with a role in health care, she said, from physicians to nurses to insurers to policymakers.

  "Obviously, our market penetration is not at all what it would be if we were to reach all of those folks," she said. Usage has been growing steadily, she added, which is another indication of the vast untapped potential.

  Whether or not the traffic level at the clearinghouse actually reflects guideline usage in practice is uncertain.

  "I don't think anyone has ever captured how often guidelines are used in practice," Slutsky said.

  But most advocates of evidence-based medicine agree that reliance on practice guidelines is lower than it should be, given that guidelines are meant to represent the best available information about the treatment of specific medical conditions. They argue that guidelines are not meant to dictate treatment plans but rather to direct physicians toward the most appropriate types of care.

  "Everyone recognizes that guidelines are just that: guidelines," said Charles M. Cutler, MD, chief medical officer of the AAHP ( "Having said that, the majority of people probably could be treated with a guideline."

Healthy Skepticism

  Following guidelines seems like a simple way to standardize medical care, but what if a guideline leads practitioners in the wrong direction?

  "There are many good reasons not to follow guidelines," said Yank Coble, MD, an endocrinologist in Jacksonville, Fla., who serves as the AMA liaison to the government's guideline clearinghouse.

  For instance, some guidelines were generated by commercial entities that had a vested interest in promoting a particular practice, he said. Others have been proven to be overly optimistic and have needed to be revised over time.

  "Physicians are appropriately concerned," he said. Many physicians rely on guidelines established by their particular specialty society, which most closely reflect their own orientations, he added.

  "Physicians tend to respond better to guidelines that are written by other physicians in their specialty, and are more suspicious of guidelines that are authored by third-party payers," said Michael Cabana, MD, MPH, assistant professor of pediatrics at the University of Michigan Health System in Ann Arbor. For instance, physicians often are skeptical of guidelines that aim to decrease hospital lengths of stay in order to save money, he said.

  Dr. Cabana and colleagues examined a variety of barriers to implementing practice guidelines in a 1999 JAMA article entitled, "Why Don't Physicians Follow Clinical Practice Guidelines?" He is concerned that guideline developers are unaware of barriers that may prevent them from being implemented.

  "Guidelines are supposed to decrease inappropriate variation and expedite the implementation of new discoveries into everyday practice," he said.

  At the same time, he does not believe that 100% adherence is a reasonable goal, because patients can be very different.

  "I would be very worried if my doctor wasn't aware of general guidelines for a certain disease," Dr. Cabana said, "but I would also be very worried if my doctor were blindly following guidelines."

   In fact, a review of nearly 300 guidelines published in peer-reviewed medical journals found that many failed to meet accepted methodological standards.

  "People say they are doing things that they're not," said Dr. Shaneyfelt, lead author of that article. Guideline writers often fail to achieve the rigorous scientific standards that they claim to use in developing practice guidelines, he said.

  Furthermore, guidelines often reflect inherent values of the guideline developers, he said, so that recommended practices from a surgical specialty might be more invasive than guidelines written by a primary care group for the same condition.

  Dr. Shaneyfelt encourages physicians to view guidelines skeptically. "There's too much blind faith out there," he said.

  On the other hand, he relies on many guidelines in his own practice of medicine. "I never intended for people to throw guidelines away completely," he said. In fact, he believes the federal clearinghouse is a reputable source because only guidelines that meet established criteria are posted there, and background information is provided to allow users to know how each guideline was developed.

  "If you want a guideline, you should go to that site," Dr. Shaneyfelt said. He even subscribes to the site's list serve, which provides email updates when new guidelines are posted.

  Unfortunately, many physicians still are uncomfortable with the Internet, which means the electronic clearinghouse may not be the best tool.

Keeping Up with the Literature

  "Guidelines are badly needed," said Keith Dahlberg, MD, a retired family practitioner in Kellogg, Idaho, who still works in hospital emergency rooms. He would welcome a type of "cookbook" that would provide general guidance on the latest methods for treating common conditions, such as diabetes, he said.

  "We can't keep up with all the literature anymore," he said. Most of the guidelines he has consulted, however, are too unwieldy, and he found the web-based clearinghouse somewhat confusing. "I want guidelines; I just want ones I can use," he said.

  Younger physicians are more likely to be trained in new information technology systems and may be more likely to use the clearinghouse in the future. Residents in some hospital programs and new physicians at some health systems are even being trained to use the clearinghouse in practice.

  "It's the only place that you can compare differences between high-quality guidelines," said John Frohna, MD, program director of medicine-pediatrics at the University of Michigan in Ann Arbor. Residents are generally receptive to the idea of consulting the website to develop treatment plans, he said.

  "There's so much out there to know, and this is one way to keep up," Dr. Frohna said. He admits that physicians in practice may have limited time or resources, but he believes that consulting guidelines ultimately can lead to better quality care.

  "The big step forward will be for organizations to look at guidelines together and decide what to do," said Health Partners official Dr. Isham. "It's hard for a given clinic or hospital or health care system at any one point in time to agree that this is the way we're going to go about it," he admitted. Some areas of the country, like the Twin Cities, are doing a much better job of that than in other areas, he said.

  When groups across the country begin reviewing and implementing guidelines in a systematic manner, the quality of health are will take a big step forward, he said.

Christine Wiebe is a freelance health and medical writer who lives in Providence, Utah. She can be reached at


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