WHY GUIDELINES?
Tee L. Guidotti, MD, MPH, FACOEM, Past President
When practice guidelines were introduced, they made almost no physician happy (except the relative few who were responsible for creating them). However, practice guidelines are here to stay. You cannot opt out. You have a huge stake in them and, for the sake of your patients and your practice as a physician, you want them to be “right.” I hope that whatever your reservations may have been in the past, if you had any, you will speak out for good guidelines in the future.
The choice is crystal clear: do you want to be led (i.e., practice medicine according to someone else’s view of what constitutes good practice) or do you want to lead (i.e., practice medicine using the best evidence codified by your colleagues who know your kind of practice and the type of patients you see). In other words, would you rather argue your own experience against the collective insight of the world’s literature or be part of the process of applying the lessons of the world and maybe even contributing to that knowledge?
Practice guidelines are the product of the movement toward evidence-based medicine that began in the UK, Canada, and the US in the last third of the 20th century. This movement had several roots: small-area analysis (which showed that one town or area might have ridiculously different rates of medical procedures with the same or poorer outcomes), critical appraisal (essentially, a systematic way of accurately reading journal articles), clinical epidemiology (which many of us joked at the time was simply epidemiology with an insufficient “n”), evaluation of medical technology (applying cost/benefit analysis, although effective regulation never took hold), the rise of randomized clinical trials (as the gold standard for treatment), and the introduction of other statistical techniques, such as meta-analysis, in an effort to approximate the apparently definitive results of trials.
Over a period of three or four decades, a small group of academics, led by Dr. David Sackett of McMaster University (Ontario), insisted on a systematic review of medical knowledge and pulled together the philosophy, refined the technology, and created the motivation to do it in practice. This led to efforts first to achieve consensus about best practices and later definitive evidence of the superiority of one treatment over another, reaching its culmination in the Cochrane Collaboration, a network of international experts who do this on a voluntary basis.
The evidence-based medicine movement was soon picked up by managed care organizations and insurance carriers, where it became a powerful business tool for achieving consistent results, achieving the best results with available resources, and cost containment. It quickly became evident that the best results for the patient usually resulted in the lowest cost to the system as a whole, at least within the scope of common medical problems. By standardizing care, managed care organizations were also able to manage their physician services and achieve flexibility in staffing (translation: we became interchangeable and therefore less expensive).
Problems soon ensued. All guidelines have their downside and for that reason they have attracted opposition in many quarters of medicine. They are constraining, may suppress physician innovation, ignore personal experience, add to paperwork, and can be applied too rigidly. On the other hand, do we really want cowboy medicine? Shouldn’t medical innovations be evaluated rigorously under experimental protocols? Is one physician’s practice a match for the world literature? Aren’t paperwork and liability going to be even worse when outcomes are poorer? Is misapplication a failure of guidelines or of the system applying them?
Implementation of guidelines was often a freewheeling catfight. Utilization review and preauthorization was sometimes inappropriate and some reviewers lacked the medical knowledge to know why. Denials of claims for reimbursement, delays, and arbitrary decisions were blamed on guidelines, whatever the real cause. Guidelines intended for simple cases were inappropriately applied to complicated cases, which they were not intended to address. Even good guidelines got a reputation as a shield behind which crafty payers could hide and became a bureaucratic nightmare. Abusive practices still occur and hurt the cause of sensible guidelines. When they are so bad as to discredit a good, solid guideline, even more harm is done because quality care for future patients is then compromised.
In 2000, David Sackett himself denounced the process (in an article in the British Medical Journal), stating that he was withdrawing from evidence-based medicine because the process had gone too far and the opinion of experts carried too much weight in medical practice. For a while it looked like the pendulum had swung as far as it would go, at least in general health care.
In the meantime, the nation’s third-largest, parallel system of health care (after general civilian medical care and the military) was in crisis (not that that was anything new). Workers’ compensation needed some good ideas, so it took some from general medicine and – as part of a reform movement – embraced the idea of guidelines, particularly in California.
We have particular evidentiary problems in occupational medicine. There are very few randomized clinical trials and it is almost impossible to implement a trial in a contemporary workplace setting. Good outcome studies are rare and worth Ed Bernacki’s weight in gold. (He wrote one.) The studies available are often weak, uninformative, and incomplete, especially on secondary issues. Many of our common conditions are shared with general medicine, but the studies available in the general medical literature almost never address work-related issues. Sometimes the evidence is just not there to support anyone’s guidelines, in which case judicious use of consensus recommendations and other “soft” evidence becomes unavoidable.
Fortunately, ACOEM got there early. For more than a decade, a dedicated and growing band of “evidentarians” in your College has formulated the ACOEM Practice Guidelines. These people know occupational medicine and understand the health and safety issues that are specific to the workplace. They understand the concepts of fitness to work, disability management, and the virtue of good outcomes leading to good results and lower costs. In situations where the evidence was not strong enough to permit reaching a conclusion, ACOEM has had the ability to find within our own membership a multitude of experts in the area of managing worker health and safety. This depth of expert knowledge enabled us to formulate consensus recommendations that are applicable to the unique needs of injured employees (or the workers' compensation population). The result was a masterful set of guidelines that gains in strength with every update. (We are currently working on version 2.1.)
ACOEM is encouraging the adoption of the Guidelines by every state. We have had successes (in California), and partial setbacks (in Texas the Guidelines is being used as the primary tool in most of the networks), but the Guidelines themselves have grown in popularity and have proven their worth. Now the objective is an integrated system that puts everybody on the same page: payers, providers (that’s us), patients, utilization reviewers, and insurance commission regulators. Ideally, the Guidelines will help end the confusion and provide harmonization of the system, so that from the time care is authorized, to when the final bill is submitted everyone is using the same database, consistently updated, and playing by the same rules.
Your College is supported by a sophisticated network of “evidentarians” organized to develop and monitor methodology, develop applications, update/evaluate new evidence, re-evaluate problem areas, and oversee the production of three major evidence-based products: the Guidelines (designed to be used prospectively), the Utilization Management Knowledgebase (a retrospective, utilization management tool based on the Guidelines and therefore entirely consistent with them), and APG Insights (an authoritative newsletter reporting on recent developments in evidence for treatment). The idea is that the care of injured workers will be guided by the best evidence applied realistically by physicians who know the workplace and care about the best outcomes for the injured worker.
The philosophy behind the Guidelines is that, properly constituted, good guidelines achieve better and more predictable results for the majority of patients, establish a standard of care, and place medicine on a defensible footing (cost-wise and in terms of liability). Properly implemented, they require the physician to justify and therefore to think through and document why something different should be done, but allows physicians to do so if there is a good reason. Properly framed, they go so far and no further and recognize that complications, multiple trauma cases, second injuries, co-morbidities, and unusual patient characteristics make the individual physician the best judge of how to proceed in exceptional cases.
Guidelines are critical to the modern practice of medicine and ACOEM is encouraging the adoption of the Guidelines by every state. Good guidelines deserve our support and the ACOEM Practice Guidelines is not only as good as it gets, but is absolutely good. They are the reflection of the world’s knowledge applied to the problems of your practice. They reflect your contribution, draw on a deep knowledge of your issues, apply to your patients, and were developed for your patients. They deserve your support and we hope that you will advocate for them in your state. You may even learn to “love” them.