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Guidelines for Clinical Practice: What They are and Why They Count

Published online by Cambridge University Press:  01 January 2021

Kathleen N. Lohr
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Are clinical practice guidelines a means for improving the quality of health care? For saving money in the health care system? For solving the malpractice problem? For making the health care system work better for all? Or, are they a recipe for disaster? This overview sets out conceptual, definitional, and practical aspects of clinical practice guidelines as a broad framework for reflecting on the issue of what guidelines are and why they count. It draws mainly on work done since 1990 at the Institute of Medicine (IOM) and focuses on five questions. First, what are guidelines, and who develops them? Second, what criteria or principles should be used to create good guidelines? Third, what problems or pitfalls exist in developing and disseminating guidelines? Fourth, in what ways can guidelines help improve medical care, and in what ways will they not be as practical or useful, particularly with respect to quality of care? Finally, what ethical context might guide deliberations on this topic?

Type
Article
Information
Journal of Law, Medicine & Ethics , Volume 23 , Issue 1 , Spring 1995 , pp. 49 - 56
Copyright
Copyright © American Society of Law, Medicine and Ethics 1995

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References

The Institute of Medicine was chartered in 1970 as a part of the National Academy of Sciences, a private, nonprofit society devoted to promoting science and technology and their use for the general welfare. The IOM, also a self-perpetuating society of distinguished scholars in all areas relating to health and medical science, enlists distinguished members of the appropriate professions in examining policy matters pertaining to public health. It acts under both the Academy's 1863 charter from the United States Congress to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education to which it should devote its attention and resources. Its work is done chiefly through expert committee, such as those that guided the work reported here on clinical practice guidelines. The author wishes to express her great appreciation to and respect for her colleague Field, Marilyn J., Ph.D., director of the studies in question. See Institute of Medicine, Marilyn Field, J. Lohr, Kathleen N., eds., Clinical Practice Guidelines: Directions for a New Program (Washington: National Academy Press, 1990); and Institute of Medicine, Field, Marilyn J. Lohr, Kathleen N., eds., Guidelines for Clinical Practice: From Development to Use (Washington: National Academy Press, 1992).CrossRefGoogle Scholar
Portions of this paper draw on Lohr, Kathleen N., “Guidelines for Clinical Practice: Applications for Primary Care,” International Journal of Quality Assurance in Health Care, 6 (1994): 17–25.Google Scholar
See Institute of Medicine (1992), supra note 1, p. 27.Google Scholar
Appropriateness denotes that “health benefits from the use of a service exceed its health risks by a sufficiently wide margin that the service is worth performing.” See Brook, Robert H., “Maintaining Hospital Quality. The Need for International Cooperation,” JAMA, 270 (1993): 985–87; see also Brook, Robert H. et al., “A Method for the Detailed Assessment of the Appropriateness of Medical Technologies,” International Journal of Technology Assessment in Health Care, 2 (1986): 53-63.CrossRefGoogle Scholar
See Institute of Medicine (1992), supra note 1, esp. App. A (pp. 243–345).Google Scholar
As of winter 1995, AHCPR guidelines have been published on the following topics: Acute pain management (for operative or medical procedures and trauma); urinary incontinence in adults; prediction and prevention of pressure ulcers in adults; management of functional impairment due to cataracts; depression in primary care (both detection and diagnosis, and treatment); sickle cell disease (screening, diagnosis, management, and counseling in newborns and infants); evaluation and management of early infection with the human immunodeficiency virus; diagnosis and treatment of benign prostatic hyperplasia; management of cancer pain; diagnosis and management of unstable angina; evaluation and care of patients with heart failure (left ventricular systolic dysfunction); otitis media with effusion in young children; quality determinants of mammography; acute low back problems in adults; and treatment of pressure ulcers. Topics under development (with expected dates of release extending into 1996) include: Post-stroke rehabilitation; cardiac rehabilitation; recognition and initial assessment of Alzheimer's and related dementias; smoking prevention and cessation; screening for colorectal cancer; chronic headache pain; and an update on urinary incontinence in adults. Under consideration are guidelines for panic disorder, osteoporosis, and early detection of breast cancer.Google Scholar
U.S. Preventive Services Task Force, Guide to Clinical Preventive Services: An Assessment of the Effectiveness of 169 Interventions (Baltimore: Williams & Wilkins, 1989).Google Scholar
Sox, Harold C. Jr., ed., Common Diagnostic Tests (Philadelphia: American College of Physicians, 1987; 2nd ed., 1990); and Eddy, David M., ed., Common Screening Tests (Philadelphia: American College of Physicians, 1991).Google Scholar
Agency for Health Care Policy and Research, Depression in Primary Care. Volume 1. Detection and Diagnosis (Rockville: Public Health Service, U.S. Dept. of Health and Human Services, AHCPR Pub. No. 93-0550, Apr. 1993); and Agency for Health Care Policy and Research, Depression in Primary Care. Volume 2. Treatment of Major Depression (Rockville: Public Health Service, U.S. Dept. of Health and Human Services, AHCPR Pub. No. 93-0551, Apr. 1993).Google Scholar
Harvard Community Health Plan. See Institute of Medicine (1992), supra note 1, pp. 333–35.Google Scholar
See Institute of Medicine (1992), supra note 1, pp. 169–70.Google Scholar
Enkin, M. Keirse, M.J.N.C. Chalmers, Iain, A Guide to Effective Care in Pregnancy and Childbirth (Oxford: Oxford University Press, 1990).Google Scholar
Vickery, D.M. Fries, James F., Take Care of Yourself (Reading: Addison-Wesley, 1990).Google Scholar
Agency for Health Care Policy and Research, Acute Pain Management: Operative or Medical Procedures and Trauma (Rockville: Public Health Service, U.S. Dept. of Health and Human Services, AHCPR Pub. No. 92-0032, Feb. 1992).Google Scholar
Agency for Health Care Policy and Research, Management of Cancer Pain (Rockville: Public Health Service, U.S. Dept. of Health and Human Services, AHCPR Pub. No. 92-0592, Mar. 1994).Google Scholar
Institute of Medicine, Durch, Jane S. Lohr, Kathleen N., eds., Emergency Medical Services for Children (Washington, D.C.: National Academy Press, 1993).Google Scholar
Id., pp. 156–67.Google Scholar
Id., pp. 167–70.Google Scholar
See Institute of Medicine (1992), supra note 1, pp. 28–32 and App. B, pp. 346-410.Google Scholar
Institute of Medicine, Lohr, Kathleen N., ed., Medicare: A Strategy for Quality Assurance (Washington, D.C.: National Academy Press, Vols. I, II, 1990).Google Scholar
Institute of Medicine, Effectiveness Initiative: Setting Priorities for Clinical Conditions (Washington, D.C.: National Academy Press, 1989); Institute of Medicine, Mattingly, Patrick Lohr, Kathleen N., eds., Acute Myocardial Infarction: Setting Priorities for Effectiveness Research (Washington, D.C.: National Academy Press, 1990); Institute of Medicine, Heithoff, Kim A. Lohr, Kathleen N., eds., Hip Fracture: Setting Priorities for Effectiveness Research (Washington, D.C.: National Academy Press, 1990); and Institute of Medicine, Lohr, Kathleen N., ed., Breast Cancer: Setting Priorities for Effectiveness Research (Washington, D.C.: National Academy Press, 1990).Google Scholar
Institute of Medicine, Field, Marilyn J. Lohr, Kathleen N. Yordy, Karl D., eds., Assessing Health Care Reform (Washington, D.C.: National Academy Press, 1993).Google Scholar
Institute of Medicine, Hogness, John R. Van Antwerp, Malin, eds., The Artificial Heart. Prototypes, Policies, and Patients (Washington, D.C.: National Academy Press, 1991).Google Scholar
Rettig, Richard A. Lohr, Kathleen N., “Measuring, Managing, and Improving Quality in the End-Stage Renal Disease Treatment Setting. Conference Overview,” American Journal of Kidney Diseases, 24 (1994): 228–34; and Schrier, Robert W. et al., “Measuring, Managing, and Improving Quality in the End-Stage Renal Disease Treatment Setting. Committee Statement,” American Journal of Kidney Diseases, 24 (1994): 383-88.CrossRefGoogle Scholar
See Institute of Medicine (1992), supra note 1, App. B.Google Scholar
Institute of Medicine, Donaldson, Molla S. Sox, Harold C. Jr., eds., Setting Priorities for Health Technology Assessment. A Model Process (Washington, D.C.: National Academy Press, 1992).Google Scholar
This phrase was coined by Roper, then administrator of the Health Care Financing Administration, in a celebrated article: Roper, William L. Winkenwerder, Warren Hackbarth, Glen H. Krakauer, Henry J., “Effectiveness in Health Care: An Initiative to Evaluate and Improve Medical Practice,” N. Engl. J. Med., 319 (1988): 1197–202.CrossRefGoogle Scholar
See Institute of Medicine (1992), supra note 1, p. 34.Google Scholar
Recognition of the importance of these elements of the health services research field is growing. For example, appropriations for AHCPR, which is responsible for the majority of public sector support for health services research and training health services researchers, grew from just over $100 to $166 million between FY 1990 and FY 1994. See Association for Health Services Research, HSR Reports, October 1994 (Washington: The Association, 1994).Google Scholar
See Institute of Medicine (1990), supra note 16, p. 4.Google Scholar
Several approaches to ethics, morality, and considered reasoning about theory, social conventions, and approved norms of conduct can be brought to bear on practice guidelines (or public policy more generally), and this paper makes no attempt to cover them all. The model applied for the IOM's work in practice guidelines, as set forth here, essentially reflects the model laid out more than a decade ago by philosophers such as Childress and Beauchamp (Beauchamp, Tom L. Childress, James F., Principles of Biomedical Ethics (New York: Oxford University Press, 1979)). The IOM's work emerged initially in a paper studying the Medicare quality assurance system (Povar, Gail J., “What Does ‘Quality’ Mean? Critical Ethical Issues for Quality Assurance,” in Palmer, R.H. Donabedian, A. Povar, G.J., Striving for Quality in Health Care. An Inquiry into Policy and Practice (Ann Arbor: Health Administration Press, 1991), pp. 129-68). More recently, Beauchamp and Childress (in Principles of Biomedical Ethics (New York: Oxford University Press, 4th ed., 1994)) characterize these ideas as “four clusters of principles” in a broader discussion of approaches to ethics and the common morality, moral and practical dilemmas, norms for human conduct, and ways of reaching considered judgments about guides to action. Although the entire field of medical ethics is rich in debate about definitions, starting points for theory, methods of reasoning, and other emphases, the model used here has proven useful for the deliberations about professional and public policy in which IOM committees often must engage.Google Scholar