Guidelines for medical practice: 2. A possible strategy.

The recognition that much current medical practice is based on incomplete scientific evidence has led to calls for the generation of guidelines for optimal patterns of practice. These guidelines must be developed from a synthesis of existing scientific data ideally obtained from randomized clinical trials. However, at present we may have to rely on less satisfactory data and the views of experts in the field. The primary purpose of these initiatives must be to improve patient care. The Ontario Medical Association has made recommendations on how such guidelines should be produced, and in a recent survey a substantial majority of family physicians supported them. There is general agreement that the coordinating body should be independent of government and other interested parties. In addition, the medical profession must have the primary role, and a number of medical organizations should also be represented. We propose a possible structure for a group charged with developing guidelines for medical practice at a provincial level and on an experimental basis. Recommendations are made on its membership, function and relationship with other organizations. The identification and diffusion of justifiable, scientific practice patterns will help reduce waste of scarce resources, maintain the role of the profession as guardian of the quality of care and ultimately benefit the patient.     

Focus: Bioethics: Practical and Ethical Considerations in Telehealth: Pitfalls and Opportunities

Telehealth has been a long-awaited advancement with the potential to improve efficiency, convenience, and quality in healthcare. However, as telehealth becomes integrated into routine clinical care, it is imperative to consider the practical and ethical implications that could undermine or devalue care delivery. The medical profession must ensure that it is implemented judiciously and with robust quality standards, guided by fair and equitable policies that balance patient autonomy with rigorous standards of care and access. Such a system must recognize the opportunity for more patient input as stakeholders to tailor care to their needs and preferences, while also acknowledging the risk of suboptimal care if convenience is prioritized over quality. More studies of optimal care models are needed to integrate data in terms of both stakeholder input and outcomes.     

Dissemination of evidence-based standards of care

Standards of care pertain to crafting and implementing patient-centered treatment interventions. Standards of care must take into consideration the patient's gender, ethnicity, medical and dental history, insurance coverage (or socioeconomic level, if a private patient), and the timeliness of the targeted scientific evidence. This resolves into a process by which clinical decision-making about the optimal patient-centered treatment relies on the best available research evidence, and all other necessary inputs and factors to provide the best possible treatment. Standards of care must be evidence-based, and not merely based on the evidence - the dichotomy being critical in contemporary health services research and practice. Evidence-based standards of care must rest on the best available evidence that emerges from a concerted hypothesis-driven process of research synthesis and meta-analysis. Health information technology needs to become an every-day reality in health services research and practice to ensure evidence-based standards of care. Current trends indicate that user-friendly methodologies, for the dissemination of evidence-based standards of care, must be developed, tested and distributed. They should include approaches for the quantification and analysis of the textual content of systematic reviews and of their summaries in the form of critical reviews and lay-language summaries.     

From autonomy to accountability: the role of clinical practice guidelines in professional power

Evidence-based medicine (EBM) aims to address the persistent problem of clinical practice variation with the help of various tools, including standardized practice guidelines. Based on a systematic evaluation of the available scientific evidence, these guidelines offer recommendations for clinicians about details of patient care and clinical decision making. Because clinical practice guidelines specify how health care should be performed, they could be considered a threat to clinical and professional autonomy. Inspired by the theory of countervailing powers, this article explores how clinical practice guidelines have shifted the focus of professional power from autonomy to accountability. Professional organizations develop clinical practice guidelines as a service to their members but do not require strict adherence to the guidelines. Indeed, implementation studies show at best a modest change in clinical behavior. Such non-adherence might render a profession vulnerable, however, when third parties seize upon guidelines and offer financial incentives to keep clinicians accountable for delivering optimal patient care.     

Reforming the NHS reforms.

Rather than improving efficiency, the reforms imposed on the NHS have increased bureaucracy, reduced patient choice, limited the range of core services, and led to inequity of treatment. In this paper I examine how the medical profession might help to solve these problems. Priorities must be set for health care since no government can afford all the possibilities offered by medical science. It is essential to forge a consensus of patients, carers, professionals, the public, and government if a system of priorities is to be equitable and just. We also need to be able to measure quality of outcome in health care. This requires consensus on what is the desired outcome and the development of appropriate guidelines, audit, and performance review. This is primarily a task for the health professions supported by management and by adequate investment. Basically, the government must reinstate the three traditional values of the NHS--equity, consensus, and regard for representative professional advice.     

Aspects of audit. 1. The background.

Methods of reviewing health care already exist in Britain, but the debate continues about how practical and acceptable such a review is. The many different terms used to describe review only confuse the issue. "Audit" is a useful term for describing the review of medical work by medical people. This can be divided into "internal audit," or peer review, and "external audit"--that is, review by organisations outside hospital and general practice. The concepts of internal and external audit have a great impact upon the attitudes held by the medical profession about audit. The shortcomings of audit by the professional standards review organisations in the United States are not inevitable in Britian.     

Attainment of Optimum Health

The history of the worker in public health is reviewed, his present activities are assessed, and predictions are made concerning his future role. It is emphasized that the public health specialist is but one member of the total health team in the community. His interdependence with other disciplines must be accepted if optimal health care is to be provided.Although prepared specifically for public health workers, this article has direct relevance to the future of the medical profession as a whole. In view of the present intense interest in the future pattern of health care in Canada, the viewpoint of a physician with a dual background in public health and medical school administration and teaching is considered to be particularly pertinent.     

Observations on ethical problems and terminal care.

Progress in medical diagnosis and therapy has raised new problems with far-reaching ethical implications. Medicine must remain a profession and not become a business. Textbooks must address ethical problems in the context of health care decisions and not restrict themselves to pathophysiology and practical therapeutics alone. The relative roles of the principles of autonomy, non-maleficence, beneficence, and justice must be balanced and appropriately applied to individual situations in biomedical ethics. When therapy becomes futile and the suffering of the patient does not justify any anticipated benefit, the patient (and/or patient surrogate) may request withholding or even withdrawing life-prolonging interventions. In the persistent vegetative state, even nutritional support by an unnatural (tube) route may ethically be denied at the patient's (or surrogate's) informed decision. New areas of ethical evaluation have been raised by the desire of some individuals to prolongation of their lives at high expense to the society such that other individuals are denied services because of limitation of available resources. There has been a long-standing conflict of interest between the acceptance by physicians and/or medical institutions of money or gifts from pharmaceutical companies whose drugs they prescribe, stock, or sell. This practice increases the cost of the drugs and is, in effect, a "sick tax," which is morally wrong.     

Medical practice guidelines: lessons from the United States.

Clinical guidelines, or protocols, have been devised by many different groups, often with differing aims. Some aim to reduce variations in care by using guidelines, while others seek to improve outcomes. Guidelines have long been used in the United States to try to control the behaviour of the medical profession--and the cost of health care. The "effectiveness initiative," run by the Agency for Health Care Policy and Research spawned much activity among other groups, including the American Medical Association and the American College of Physicians. The experience of the Americans in analysing data to gauge effectiveness and then in disseminating good practice may help British moves in this direction. In particular, it is often hard to get guidelines adopted in practice; doctors have to be exposed to the same message in different forms. Also guidelines must not be unrealistic: those devised by senior doctors away from the realities of day to day practice are likely to fail.     

Gestational and Perinatal Factors in Brain Damage

Until relatively recently, studies in this field emphasized the physical events surrounding the transfer of the infant from the uterus to the bassinette. Current investigators are devoting much more attention to intrauterine and early neonatal environment. This is not to say that mechanical factors should be forgotten or that they are unimportant, but that there seem to be factors as yet unknown which in modern practice may make a significantly greater contribution to the problem of brain damage than does direct obstetric trauma.Genetic, developmental and infective factors have been reviewed. The interrelated factors of prematurity, anoxia, trauma and brain hemorrhage have been discussed. The contribution which traumatic obstetrics has made to the problem of brain damage can be minimized by general application of standards of obstetric care and practice which are now well established. The modern practice of obstetrics must extend its active interest far beyond the goal of a living mother and child-the future health of both must be its concern. Obstetrics must be considered as an opportunity to practise a philosophy of preventive medical care in the broadest sense.     

Internal quality audit and quality standards as a method of quality improvement at the Department of Ophthalmology, University Hospital

Quality assessment of clinical health care with the programme of quality standard is a method of health management, through which better efficiency and safety of health outcomes can be achieved. In the period from 2002 to 2004, a pilot program of quality has been carried out on the Department of Ophthalmology, University Hospital Center in Zagreb. Seven internal audit teams of hospital commission and teams of hospital departments were evaluating introducing practice for quality standards every three months. In the period of two years improvement in all standards of quality has been noticed (expressed in percent of progress towards the ideal result of 100%): personnel 20%, patient rights 15%, medical equipment 40%, quality of emergency service 60%, implementation of clinical guidelines and criteria for elective admission 55%, quality of risk prevention 70%, quality of medical records 60%. The two-years-improvement dynamics of about 46%, first year 24%.     

Appropriateness in health care delivery: definitions,measurement and policy implications.

A major focus of the current health care debate is the notion that a substantial proportion of the health care delivered in Canada is inappropriate. There are two types of appropriateness: appropriateness of a service and appropriateness of the setting in which care is provided (i.e., inpatient v. outpatient or home care). Measuring both types objectively requires the comparison of observed patterns of care with explicit criteria for appropriate care. The few studies of appropriateness conducted in Canada have shown that inappropriate services are provided and inappropriate settings are used. Reducing inappropriate health care delivery could involve active strategies for the implementation of guidelines and better cooperation and coordination within the health care system. However, lower rates of health care delivery or even inappropriate health care will not necessarily translate into higher quality care or lower costs overall.     

Guidelines for reading literature reviews.

One strategy for dealing with the burgeoning medical literature is to rely on reviews of the literature. Although this strategy is efficient, readers may be misled if the review does not meet scientific standards. Therefore, guidelines that will help readers assess the scientific quality of the review are proposed. The guidelines focus on the definition of the question, the comprehensiveness of the search strategy, the methods of choosing and assessing the primary studies, and the methods of combining the results and reaching appropriate conclusions. Application of the guidelines will allow clinicians to spend their valuable reading time on high-quality material and to judge the validity of an author''s conclusions.     

Medical malpractice in perspective. II--The implications for Britain.

The "malpractice crisis" in the United States cannot be understood in isolation. Litigation is precipitated by features of the American health care and social security systems. Relative to the United Kingdom, there are fewer barriers of access to the courts, although the role of contingency fees has probably been exaggerated. Given the great institutional differences between the UK and the USA, the crisis seems unlikely to be replicated here unless there are further moves towards privatising both the costs of providing health care and the costs of its failures. It is concluded that a marginal change in the frequency or average cost of claims could have a serious impact on National Health Service resources, the medical defence societies, recruitment to specialties, and clinical practice. Debate over possible reforms is compromised by the dearth of good empirical data. Any changes, however, must address both the deterrence of bad practice and the compensation of injured patients.     

Diagnostic imaging at its centennial: the past,the present and the future.

Since the discovery of x-rays by Wilhelm Conrad Röntgen 100 years ago, diagnostic imaging has profoundly influenced the practice of medicine. As a result of discoveries during this period, ultrasonography, nuclear imaging, computed tomography and magnetic resonance imaging, as well as conventional radiography, have assumed a major role in diagnostic medicine. In addition to their traditional role in diagnosis, imaging techniques are becoming an increasingly important factor in innovative treatment methods, and this role is likely to expand. In the current climate of rising health care costs, radiologists and other health care providers who use imaging must increasingly account to health care funders for the cost-effectiveness of imaging in relation to other diagnostic and interventional techniques. They must also assure minimum standards of quality and training, and determine the appropriate role for diagnostic imaging in health care systems of the future.     

Aspects of audit. 4: Acceptability of audit.

Whether or not audit is accepted in Britain will be determined principally by how it is controlled, how much it costs, and how effective it is. The objectives of audit have been defined as education, planning, evaluation, research, and anticipatory diplomacy--that is, starting internal audit before external audit is imposed on the medical profession. Published reports suggest that in Britain internal audit would be more effective andless expensive than the complex professional standards review organisation devised by the Federal Government in the United States.     

Influence of the Royal College of Radiologists' guidelines on hospital practice: a multicentre study. Royal College of Radiologists Working Party.

OBJECTIVE--To measure the effect on hospital radiology referral practice of introducing a strategy for change involving guidelines of good practice, monitoring, and peer review. DESIGN--Prospective data collection over a continuous 21-24 month period at each centre some time between January 1987 and December 1990. SETTING--Five district general hospitals and one district health authority. SUBJECTS--314,663 inpatient discharges, deaths, and day cases and 1,706,781 outpatient attendances under the care of 722 consultants from 25 clinical specialties. MAIN OUTCOME MEASURES--Number of referrals for x ray examination per 100 inpatient discharges, deaths, and day cases and per 100 new outpatient attenders. RESULTS--Most doctors were prepared to accept standards of clinical practice set by peers and also the monitoring and review of their practice with respect to these standards by local colleagues. 18% of firms were identified before guidelines were instituted as having persistently high referral rates. Appreciable, and often dramatic reductions in referral rates for individual x ray examinations were recorded by a substantial number of firms in every centre and in every specialty after guidelines were instituted. The major part of this reduction was achieved by some of the firms whose initial practice did not meet "high referral" criteria. Important variations in compliance with agreed standards of good practice were observed. CONCLUSIONS--The study offers strong experimental evidence to support a recent suggestion that at least a fifth of radiological examinations carried out in NHS hospitals are clinically unhelpful. The problem of how to assure compliance with agreed standards of practice needs to be resolved. Until this happens medical audit alone is unlikely to translate good practice into common practice.