Healthcare policy, medical practice, and cost of care are no longer considered distinct
entities. Each is an integral factor in determining not only what, but how, patient care
will be delivered. Clinical practice guidelines are the lynchpin that connects
them. This paper addresses the various components of the
clinical practice guideline—cost alliance.
Objective: To examine the bidirectional influence of choice of care on costs
and of cost of care on decision making.
Methods: The literature was used to identify cost-related
factors that influence development of guidelines and change in physician practice
behavior. In a MEDLINE search with modifiers to the keywords “clinical practice
guidelines,” particular attention was paid to identifying surveys of practitioners. An
analysis, prompted by a recently published guideline, of treating
penetrating intraperitoneal colon
injuries by different surgical approaches (primary repair versus diverting colostomy)
exemplified how implementation of a guideline can affect the cost of care. Inpatient
cost estimates, adjusted for medical inflation and cost-to-charge ratios and reported in
1999 U.S. dollars, were developed using data from 1996 and 1997 discharge databases from
California and Massachusetts.
Results: The results showed that a substantial savings in hospital costs was
achieved when a primary repair surgical technique, as advocated by the
guideline, was used. The effect of cost influences on the development of
clinical practice guidelines was
established by demonstrating the cyclical effect between usual and customary
practices, guideline implementation, changing practice patterns, and the economic
considerations influencing the process.
Conclusions: A growing, albeit uneasy,
alliance between costs and clinical practice guidelines is evident.