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Do we need to use Antibiotics...

Quality controlled: Putting practice guidelines to work
Evidence-based practice guidelines are increasingly touted as the key to quality care. Now the push is on for physicians to prove they're following along.
By Andis Robeznieks, AMNews staff. Dec. 23/30, 2002. Additional information
Not too long ago, when a child came into a doctor's office with an ear infection, the standard practice was to prescribe a 10-day supply of antibiotics. No questions asked."It turns out antibiotics weren't needed -- or at least not for 10 days, but that evidence is just coming out," said Mary E. Frank, MD, an American Academy of Family Physicians board member who received her medical degree in 1973.

"I think one of the things physicians are caught on right now is that, a lot of things we've done forever, we have no evidence on," she added. "Antibiotics for ear infections was something you were taught, and it continues to be published."

Old practices such as this are being put to rest, because evidence shows that 80% of patients with uncomplicated infections recover within one to seven days without antibiotics; and, of those treated with antibiotics, 93% recover during the first week.

Evidence-based practice guidelines have become an integral part of the quality movement in health care but Dr. Frank -- who heads a five-physician practice in Rohnert Park, Calif. -- said physicians are being flooded with new and, occasionally, conflicting information, and sometimes it's just too much to process.

"You're taught that patients are individuals and taught to make individual assessments. Now they're saying, 'Don't do it,' and you don't know what to do," she said. "The result is you get people who say, 'I don't know what to make of this, so I'll just keep doing what I always did.' "80% of patients with uncomplicated infections recover within a week without antibiotics.

That isn't likely to work indefinitely, however, because current calls for using evidence-based practice guidelines are accompanied by a requirement to document their use.

Dr. Frank said this is difficult for physicians who have yet to adopt electronic record-keeping. For example, doctors who use electronic medical records may be able to find out how many of their 5-year-old patients are getting immunizations with just a few keystrokes. But for doctors who use a paper system, getting that same information is a multistep process. First, Dr. Frank said, a list with all the names of patients younger than 5 would have to be printed out, and then each of their individual files would have to be pulled and checked.

"That's where the information glitch is," she said, adding that the AAFP soon will launch a drive to get 5,000 offices (representing 20,000 to 30,000 physicians) equipped with EMR technology by 2005.

If trends continue, drives like these are definitely needed.

Cookbook medicine
Sometimes derided as "cookbook medicine," practice guidelines are described by many insurance companies and business groups as key ingredients in the quality-of-care recipe. These organizations are also cooking up different ways to get doctors to adopt the practice guidelines they think are best.

Dr. Frank said she's even heard of a proposal to report physicians to licensing boards if they don't adhere to certain quality standards.It takes an average of 17 years for original medical research to be put into common practice. "There's a way to do it without getting punitive," she said. "I think sticks don't work as well as carrots."

Nevertheless, Dr. Frank admits that some type of incentive is often needed as studies show it takes an average of 17 years for original research to be put into common practice.In hopes of speeding up the process, myriad organizations have established guidelines and are urging physicians and institutions to adopt them. Among those who have developed guidelines are the Leapfrog Group, a national consortium of 125 companies employing up to 33 million people; the Midwest Business Group on Health, a group with more than 70 member companies in a six-state region; and the Committee for Economic Development, a national organization of 250 business leaders and educators.

The CED has called for designing managed care contracts that develop custom strategies for "the 10% of patients who account for 70% of health spending." It also calls on physicians to adhere to evidence-based standards and advocates rewarding physicians who help people stay well, at a lower cost, rather than treating them after they get sick, and incurring more expenses.

Recognizing one size does not fit all Perhaps the best-known practices being advocated by employers are the Leapfrog Group safety practices, which include: using computerized physician order entry to submit prescriptions, staffing intensive care units with trained specialists and referring high-risk surgeries or conditions to hospitals with high annual volumes and experience with those surgeries and conditions. Leapfrog Executive Director Suzanne Delbanco, PhD, said the call for uniform standards is not the same as advocating a one-size-fits-all approach to medicine.

"We know every patient is different, but -- if there is research suggesting that certain practices, on average, improve patient care -- I think that is something that should be adhered to," she said. "The reason why physicians think of it as 'cookbook medicine' is because they consider the complexity of how patients vary and don't feel one protocol is appropriate for all.

"But there is certain evidence that certain things work," Dr. Delbanco added. "There is a huge need for greater adherence to what the evidence says works, and that's what practice guidelines are meant to do."

Even the American Heart Assn. is getting into the act. The AHA has its "Get With The Guidelines" program, which is designed to save 80,000 lives annually. The organization spent $337 million conducting research and professional education on the guidelines, which seek to close the "treatment gap" after an initial heart attack that often can lead to another heart attack or disabling heart failure.

If a hospital develops or revises existing protocols in accordance with the AHA's secondary prevention guidelines, then submits patient data and other proof that the policy has been implemented, it can be designated a GWTG-Coronary Artery Disease Hospital. After this designation, an institution can receive a "performance achievement award" if it shows compliance rates of at least 85% with eligible patients.

The other part of the quality equation is performance measures.

"Performance measures are derived from guidelines, but they are not the same thing," said Karen Kmetik, PhD, a clinical quality improvement specialist with the American Medical Association. "A measure tells us how often something in a guideline has been done."

Certain groups are offering physicians financial incentives if they meet the group's performance measures.

Most recently, a group of California purchasers, health plan directors, physician group executives and medical directors formed the Integrated Healthcare Assn., which launched a pay-for-performance initiative based on patient satisfaction, prevention, chronic-care management and information-technology investment.

If physicians follow the prescribed guidelines and meet the measures, a performance bonus will be issued.

Whose guidelines?
Some physicians may feel they deserve a bonus just for slogging through stacks of paperwork.

"We accept 14 different insurances plus Medicare and Medicaid," Dr. Frank said. "I have binders with all their guidelines, and they all have guidelines -- for asthma, diabetes, back pain, you name it.

"One week, Health Net will send you their diabetes guidelines, then PacifiCare will send you their diabetes guidelines, and then Brand X will send you their diabetes guidelines," she added. "If you scan them all and all 14 look the same, you can throw 13 of the 14 away."

And although different organizations might -- more or less -- require the same practices for diabetes management, Dr. Frank said that is not the case for all conditions, and treatment guidelines for prostate cancer, for example, vary from organization to organization.

"There's not necessarily consistency from one group to another," she said. "Some docs just throw them away; others go back and check each file individually one by one."

So the challenge becomes not only to get physicians to adopt the guidelines, but also to obtain and learn how to use and implement the technology.

In an initiative funded by an Agency for Healthcare Quality and Research grant, the AMA's Dr. Kmetik is heading a coalition of physicians, employers, health plans and payers in an effort to get all the players reading from the same quality playbook.

But Dr. Frank has her own ideas on the subject of quality, and they don't necessarily include performance measures and financial incentives.

"Quality has a broad definition," she said. "Quality isn't measured by how many Pap smears you do or how many immunizations you give.

"As a family doctor, the reward is when I see patients for a long time and I see people who live longer, healthier, and are more productive. Where I practice, in Sonoma County, Calif., that has to serve as my reward."