July 1995 Bulletin

Academy moves ahead on guidelines

Developed to support appropriate clinical decisions

by Kenneth E. DeHaven, MD,

Kenneth E. DeHaven, MD, is Academy First Vice President,Chairman, Task Force on Guidelines

Escalating health care costs and the proliferation of managed care has forced health care providers, and the professional organizations with which they are associated, to develop solutions that may improve the quality of care and simultaneously reduce health care costs. Faced with this challenge, the Academy, like other professional and educational organizations, has initiated a number of efforts designed to help its membership adapt. Examples of Academy initiatives in this area include numerous publications and education programs on global services data, outcomes studies and utilization review, and the development of clinical guidelines (policies and algorithms).

In December 1994, the Academy's Board of Directors created a task force to examine past Academy initiatives in this area; assess the current status of guidelines projects; and make specific recommendations for the oversight, development, and implementation of future Academy guidelines initiatives. This task force, which I chair, consists of representatives from the Board of Councilors, Council of Musculoskeletal Specialty Societies, Council on Research and Scientific Affairs, Council on Health Policy and Practice, Council on Education, four at-large members, and four consultants.

The current status of Academy guidelines projects includes revision of the 15 existing clinical policies, completion of field testing of the two pilot phase II (specialty physicians) algorithms (low back pain and knee pain). It is important to emphasize that these are all developed by physicians for physicians with the goal of supporting appropriate clinical decisions in both fee-for-service and capitated managed care environments. They all have been developed using a combination of scientific literature and expert consensus as the basis for recommendations. None of the Academy's guidelines have been validity-tested, but the algorithm field testing is the first step in this process. The Academy is committed to replacing consensus with evidence-based guidelines as the information becomes available.

Include MCOs

In addition to developing and testing guidelines that are valid and usable, we also want to seek widespread acceptance and utilization of our guidelines. The task force realized that this cannot occur without managed care organizations (MCOs) incorporating them, and to maximize the likelihood for this to occur, we need to involve MCOs in the evaluation and testing process.

Another area that the task force analyzed was the medical-legal implications of guidelines. A frequently raised concern is that increased professional liability would occur as a consequence of developing guidelines. Extensive survey of existing experience, including case studies, indicates that guidelines have been used by both defense and plaintiff attorneys. The total number of cases to date has been small, none has involved an orthopaedic surgeon, and there is no way to identify the number of cases that were never litigated because of the existence of pertinent guidelines that were in support of the care provided by the physicians. It is believed to be very unlikely that a suit would be brought solely because of guidelines, but rather that the guideline in question would be used to support other lines of evidence.

Need rationale

However, it is important to emphasize that one needs to document the rationale for deviating from the guidelines in the management of an individual case. Also, 13 states have enacted or are considering legislation to establish state guidelines. Some include language that allows the use of guidelines in the defense of physicians being sued who have been within guidelines, but also state that the guidelines do not dictate a standard of care.

In May 1994, the Task Force on Guidelines presented its report to the Board of Directors and received unanimous support for its recommendations regarding the future direction and oversight of a comprehensive guidelines project. The following represents the recommendations presented by the Task Force on Guidelines and approved by the Academy's Board of Directors:

  1. Create an Oversight Committee on Guidelines consisting of at least six members which will function as a standing committee of the Council on Research and Scientific Affairs.
  2. Initiate a dialogue with associations representing managed care organizations and maintain this relationship for the purpose of forging partnerships to assess the utility of its guidelines and other relevant issues.
  3. Support the American Medical Association and its efforts regarding medical liability aspects of clinical guidelines including promoting their use as exculpatory evidence in litigation. It is further recommended that this function be monitored by the Academy's Office of the General Counsel.
  4. That the Academy promote action at the state level, through the Board of Councilors and the state orthopaedic societies, to use guidelines to reduce defensive medicine and to seek to have the Academy guidelines incorporated into state guidelines for musculoskeletal health care.

Membership for the Oversight Committee on Guidelines will include representation from the Council on Education, the Council on Health Policy and Practice, the Board of Councilors, the Council of Musculoskeletal Specialty Societies, and a member at-large. A minimum of three nonorthopaedic consultants will also be required to facilitate work and provide liaison with other guidelines developers and organizations. The following individuals have been appointed to serve on the oversight committee: Aaron Rosenberg, MD, chairman; Rick Reed, MD, Board of Councilors; David Lewallen, MD, COMSS; Paul Hirsch, MD, Council on Health Policy and Practice; Freddie Fu, MD, Council on Education; and David Wong, MD, member at-large of the committee.

The Oversight Committee on Guidelines will assume the ongoing responsibilities of the previous Committee on Clinical Policies, the Algorithm Task Force, and the Task Force on Guidelines, all of which have been retired.

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