WASHINGTON — One of the biggest barriers to guideline implementation is lack of a champion to encourage use of the guidelines at a particular institution, Dr. Rodger Winn said at a conference sponsored by Elsevier Oncology.
The idea of practice guidelines “is about as apple pie and motherhood as you can get,” said Dr. Winn, director of the Quality of Care Measures Project at the National Quality Forum (NQF), a nonprofit organization. “How can that not be translated into practice? Yet we know from a lot of studies that it hasn't happened.”
Several of the barriers to guideline use are fairly obvious, according to Dr. Winn. For instance, “if a guideline is too complex and you just can't follow it, it's not going to be used.”
There are patient-related barriers, as well. That can span everything from the recommended treatment not being paid for by the insurer to the recommendation being for radiation but the patient living 100 miles from the nearest radiation facility, he said.
Attitudinal barriers on the part of providers also are a problem. Providers may not agree with the guideline; the guideline may recommend something the provider doesn't believe he can accomplish; and the provider may not believe a particular guideline is going to work.
“If you don't believe the next monoclonal antibody really adds 3 months' median survival, you're not going to go along with it,” Dr. Winn said.
But one of the tougher barriers is clinical inertia—“you know it's sort of right but you don't do it anyway,” he said. “It's a well-known phenomenon in medicine.”
Randomized trials have shown that one way to overcome that inertia is to use “trusted leaders” to implement the guideline. “You literally have to go back to your own institutions and become champions for this,” Dr. Winn urged the audience.
He cited a clinical trial done in 16 Canadian hospitals in which some hospitals were assigned “audit and feedback” sessions regarding guidelines for repeat C-sections, while others also included an “opinion leader” to educate physicians about the new guideline. Those that used an opinion leader did much better at implementing the guideline (JAMA 1991;265:2202–7).
All the focus on guidelines is now leading up to quality measurement, Dr. Winn said. He noted that one expert split health care quality into three parts: structure (what's already in place, such as how many certified nurses you have); outcomes (what happens to the patient); and process (what you do to the patient that leads to those outcomes). “We'd like to say that outcomes are what ultimately define quality, but the problem is, it's not always as simple as that” because outcomes may vary for a variety of legitimate reasons. As a result, “outcomes in medicine may not be the proper measure of quality; it may be process. What did we do to the patient?”
Clinical practice guidelines, in fact, are process maps, he said. “They tell you what you should do to the patient. Therefore, if you measure adherence to guidelines, you're doing process measurement. The big assumption there is that the guidelines are valid and that these processes do lead to better outcomes.”
One question that is bound to come up more often as guidelines come into wider use is accountability. “Let's take breast-conserving surgery postop radiation therapy,” Dr. Winn said. “Is it the hospital's job to [make sure that] the patient got radiation after breast-conserving surgery? If you're at Memorial Sloan-Kettering and the patient goes back [home] to Queens, is that your job to make sure they got it? Which physician is in charge?”
Dr. Winn predicted two organizations will become increasingly prominent as guidelines proliferate: the NQF and the Cancer Quality Alliance. The NQF helps organizations decide which quality measures are worth using; its voluntary measure sets are already accepted by Medicare, “and we make sure that consumers, payers, health plans, and providers are there for a very formal review process,” he said. The Cancer Quality Alliance, set up by the American Society of Clinical Oncology and the National Coalition for Cancer Survivorship, “is still trying to define what its role is,” he said.
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