Text-to-algorithm conversion to facilitate comparison of competing clinical guidelines.

This study aimed to test the usefulness and reliability of text-to-algorithm conversion in comparing competing clinical guidelines and defining their differences. Two pairs of competing guidelines for measles immunization, published in 1989 and 1994, were analyzed and compared. Five categories of differences were detected: differences in recommendations, excluded elements, logical inconsistencies, nonspecific phrases, and approaches to contraindications. On a scale of 0-10 (where identical=10), the overall comparison scores were 6.01 for the guidelines published in 1989 and 5.54 for the guidelines published in 1994. Text-to-algorithm conversions performed by three different persons on the 1989 guidelines were compared and found similar. Text-to-algorithm conversion is an important step in facilitating comparison of competing guidelines. It has the potential to assist in making rational and systematic choices between competing guidelines before actual field testing takes place. Physicians can use it to analyze and to learn a prose clinical guideline, to critique existing guidelines, and to simulate hypothetical patients for teaching and evaluating clinical management.

Attitudes about clinical practice guidelines in a mixed model HMO: the influence of physician and organizational characteristics.

OBJECTIVE: This study assesses physician attitudes toward clinical practice guidelines, in an organization where guidelines have long been incorporated into the clinical practice. Attitudes toward institutional guidelines and guidelines in general are explored, and are compared to a published study describing attitudes among a sample of American College of Physician (ACP) members. DESIGN: Descriptive study. SETTING: A large, mixed model HMO. SAMPLE: Two hundred and three internists and family practice physicians. MEASURES: Attitudes toward perceived compliance with clinical practice guidelines were assessed. Summary measures of attitudes and anticipated impact of guidelines were created. RESULTS: Overall, attitudes toward practice guidelines among HMO physicians were very positive. Differences were observed by gender, practice model, years in practice and residency training. HMO physicians on average held more favorable attitudes toward guidelines compared with published results of an ACP survey. While HMO physicians in independent group practices viewed the concept of guidelines less favorably than staff model physicians, they were more likely to view the impact of guidelines positively than were the ACP physicians. CONCLUSIONS: Exposure to practice guidelines in the context of clinical practice can lead to positive attitudes about those guidelines. While resentment toward a system which relies on practice supports such as guidelines may remain among some physicians, this need not be inconsistent with an appreciation of the potential value of guidelines for improving clinical quality.

Discontinuations of antihyperlipidemic drug therapy: assessment by means of automated databases.

Discontinuations of drugs used in the treatment of chronic conditions such as hyperlipidemia often signal adverse drug effects or therapeutic ineffectiveness. Discontinuations of antihyperlipidemic drug therapy among 2369 patients were evaluated using the computerized files and written medical records of two health maintenance organizations (HMOs) in Massachusetts for the period 1988 to 1990. Three methods were assessed for the identification of potential discontinuations of drug therapy using the automated databases. Overall, 75% of discontinuations flagged by the automated databases were confirmed in the medical charts. (1) In new users, 618 of the 635 (97%) drugs identified as drug switches by the computerized HMO pharmacy files were confirmed as discontinuations by the medical charts. (2) Of 620 eligible HMO members 332 (54%) identified with greater than 6 months between the last refill for an antihyperlipidemic drug and the end of the study stopped the drug therapy according to the medical chart. (3) Of 219 eligible drug therapies flagged with an 'inactive' or with an 'omit' status in the clinical encounter files 198 (90%) were discontinued according to the medical chart. This study demonstrates the utility of clinical automated databases to facilitate the study of drug discontinuations in primary care settings, reducing the cost and the amount of time required for the evaluation.

Is consensus reproducible? A study of an algorithmic guidelines development process.

The authors evaluated the reproducibility of a clinical algorithm consensus development process across three different physician panels at a health maintenance organization. Physician groups were composed of primary care internists, who were provided with identical selections from the medical literature and first-draft "seed" algorithms on the management of two common clinical problems: acute sinusitis and dyspepsia. Each panel used nominal group process and a modified Delphi method to create final algorithm drafts. To compare the clinical logic in the final algorithms, the authors applied a new qualitative and quantitative comparison method, the Clinical Algorithm Patient Abstraction (CAPA). Dyspepsia algorithms from all physician groups recommended empiric anti-acid therapy for most patients, favored endoscopy over barium swallow, and had very similar indications for endoscopy. The average CAPA comparison score among final physician algorithms was 6.1 on a scale of 0 (different) to 10 (identical). Sinusitis algorithms from all groups proposed empiric antibiotic therapy for most patients. Indications for sinus radiographs were similar between two algorithms (CAPA = 4.9), but differed significantly in the third, resulting in lower CAPA scores (average CAPA = 1.9, P < 0.03). The clinical similarity of the algorithms produced by these physician panels suggests a high level of reproducibility in this consensus-driven algorithm development process. However, the difference among the sinusitis algorithms suggests that physician consensus groups using a consensus process that a health maintenance organization can do with limited resources will produce some guidelines that vary due to differences in interpretation of evidence and physician experience.

Discontinuation of antihyperlipidemic drugs--do rates reported in clinical trials reflect rates in primary care settings?

BACKGROUND: Discontinuation rates for drugs used to treat chronic conditions may affect the success of therapy. However, the discontinuation rates reported in clinical trials may not reflect those in primary care settings. METHODS: We conducted a cohort study using computerized research files and medical records on 2369 new users of antihyperlipidemic therapy at two health maintenance organizations (HMOs) from 1988 through 1990. The rates of drug discontinuation in these primary care settings were compared with the rates reported in clinical trials published from 1975 through 1993, located with the Medline data base. RESULTS: In the HMOs, the one-year probability of drug discontinuation was 41 percent for bile acid sequestrants (95 percent confidence interval, 38 to 44 percent), 46 percent for niacin (95 percent confidence interval, 42 to 51 percent), 15 percent for lovastatin (95 percent confidence interval, 11 to 19 percent), and 37 percent for gemfibrozil (95 percent confidence interval, 31 to 43 percent). For the bile acid sequestrants, niacin, and gemfibrozil, the risks of discontinuation were substantially higher in the HMOs than in randomized clinical trials, in which the summary estimates of this risk were 31 percent, 4 percent, and 15 percent, respectively, for trials of one year or longer. The rates of discontinuation in open-label studies were similar to those in the HMOs. CONCLUSIONS: The discontinuation rates reported in randomized clinical trials may not reflect the rates actually observed in primary care settings. The effectiveness and tolerability of antihyperlipidemic medications should be studied further in populations that typically use the agents.

Anticoagulation in atrial fibrillation. Does efficacy in clinical trials translate into effectiveness in practice?

BACKGROUND: Several recent randomized clinical trials of anticoagulation in atrial fibrillation have demonstrated significant reduction in stroke rates with a small incidence of bleeding complications. The objective of this study was to determine whether the recommendations resulting from these trials have been implemented into routine practice, and if the anticoagulation control, therapeutic efficacy, and low complication rates achieved in the trials have been matched in community practice. METHODS: We analyzed the anticoagulation practices and outcomes obtained for patients in atrial fibrillation at a large staff model health maintenance organization (HMO). We reviewed the medical records of all patients in atrial fibrillation as of April 1990. We compared demographic characteristics and clinical risk factors between HMO patients and those in the clinical trials. We also compared anticoagulation monitoring, adequacy of anticoagulation control, and clinical outcomes at the HMO with those achieved in the clinical trials. RESULTS: Of 238 HMO patients in atrial fibrillation, 198 were without contraindications and therefore eligible for anticoagulation. Of these, 168 were offered anticoagulation (84.8%) and 156 were receiving anticoagulation therapy (78.8% of those eligible). The HMO patients had a greater prevalence of comorbidities than those in the clinical trials. The routine monitoring interval at the HMO was estimated at between 36.3 and 40.9 days (compared with 21 to 28 days reported in the clinical trials). The prothrombin time ratios at the HMO were in the target range on 50% of days compared with 68% of days in the clinical trials. The annual stroke and major bleeding rates in the HMO patients (1.3% and 0.6%, respectively) were not significantly different from the rates in the clinical trials (1.3% and 1.1%, respectively). The annual minor bleeding rate of 13.6% at the HMO was greater than the 7.8% to 8.4% rates in the two trials with better anticoagulation control (Boston Area Anticoagulation Trial for Atrial Fibrillation and Stroke Prevention in Atrial Fibrillation Study) but was not significantly different than the rates of 12.7% and 13.7% of the two trials with poorer anticoagulation control (Canadian Atrial Fibrillation Anticoagulation Study and Stroke Prevention in Nonrheumatic Atrial Fibrillation Study). CONCLUSIONS: Anticoagulation practices in this community setting appear to be good in that a large majority of patients were receiving anticoagulation therapy, and there were few major adverse outcomes. However, this study illustrates two common problems in attempting to apply the results of randomized clinical trials to routine practice: (1) differences between community patient populations and those on which the conclusions of clinical trials are based, and (2) less successful application of therapeutic interventions in settings other than that of a controlled clinical trial. The greater prevalence of comorbidities in the HMO patient population appears to convey a greater overall risk of thromboembolism and bleeding complications than in the clinical trials. In addition, the suboptimal anticoagulation control achieved at the HMO may increase the risks and decrease the potential benefits compared with those achieved in the clinical trials. Thus, the efficacy demonstrated in the clinical trials of anticoagulation in atrial fibrillation may not be directly translated into effectiveness in practice.

Implementing clinical guidelines: a quality management approach to reminder systems.

"Reminders" (timely notices about specific clinical events to physicians or patients) are useful strategies for implementing clinical guidelines. These systems can vary widely in content, design, and purpose. This variability makes it difficult to compare systems or predict a reminder's efficacy in a particular setting. In this article, the authors suggest that too much attention has been paid to proving the efficacy of reminder systems as a general strategy or a comprehensive solution. Rather, the usefulness and effectiveness of reminder systems will be better appreciated when quality management principles are applied to designing, implementing, and maintaining them. Physicians must participate in finding the best solutions for clinical process problems, and reminder systems--when implemented as the "best solution"--must be monitored and improved continually on an ongoing basis to continue to meet physicians' needs.

What's preventing more prevention? Barriers to development at academic medical centers.

OBJECTIVE: To determine the views of leaders in academic medicine concerning the need for programs in preventive medicine (PM) and the prevailing barriers to program development. DESIGN: Structured interviews. SETTING: Medical schools of the United States. PATIENTS/PARTICIPANTS: 90% of deans and chairpersons of departments of medicine and preventive medicine. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: 91% considered academic PM underdeveloped and 100% considered their own programs average or worse. Identified barriers to development included funding constraints, academic partiality to biomedicine, inadequate quality of preventive medicine research and faculty, public preferences for technologic care, and organization of academic medical centers (AMCs). While 80% perceived a shortage of able PM faculty and 60% considered PM research quality to be inadequate, only 12% of PM units gave research training high priority. While 95% of respondents held that AMCs should develop community programs and 75% identified social problems as a cause of chronic diseases, 65% agreed that community programs are not considered scholarly. Only 23% of PM units gave community service high priority. CONCLUSIONS: A policy contradiction exists: academic leadership agreed on the problems and needed changes in PM, yet the problems were often attributed to nonacademic sources, particularly finding and public preferences, and current academic practices commonly fail to address recognized developmental barriers within academic institutions. A chain of barriers is apparent. Breaking the chain may require a change in our understanding of the role of prevention.

The clinical algorithm nosology: a method for comparing algorithmic guidelines.

Concern regarding the cost and quality of medical care has led to a proliferation of competing clinical practice guidelines. No technique has been described for determining objectively the degree of similarity between alternative guidelines for the same clinical problem. The authors describe the development of the Clinical Algorithm Nosology (CAN), a new method to compare one form of guideline: the clinical algorithm. The CAN measures overall design complexity independent of algorithm content, qualitatively describes the clinical differences between two alternative algorithms, and then scores the degree of similarity between them. CAN algorithm design-complexity scores correlated highly with clinicians' estimates of complexity on an ordinal scale (r = 0.86). Five pairs of clinical algorithms addressing three topics (gallstone lithotripsy, thyroid nodule, and sinusitis) were selected for interrater reliability testing of the CAN clinical-similarity scoring system. Raters categorized the similarity of algorithm pathways in alternative algorithms as "identical," "similar," or "different." Interrater agreement was achieved on 85/109 scores (80%), weighted kappa statistic, k = 0.73. It is concluded that the CAN is a valid method for determining the structural complexity of clinical algorithms, and a reliable method for describing differences and scoring the similarity between algorithms for the same clinical problem. In the future, the CAN may serve to evaluate the reliability of algorithm development programs, and to support providers and purchasers in choosing among alternative clinical guidelines.

Algorithm-based clinical quality improvement. Clinical guidelines and continuous quality improvement.

Evidence documenting unexplained variation in clinical practices and outcomes has led to a proliferation of clinical practice guidelines in the hope that such efforts will lead to decreased variation, improved care, better outcomes, and lower costs. At Harvard Community Health Plan we have developed a clinical guideline development effort that focuses on the development of clinical algorithms and guidelines in a quality improvement model. The formal quality improvement process that we have described requires; (1) clear project definition and organization, (2) guideline development based on an understanding of patient needs, scientific evidence and clinical experience, (3) thorough analysis of potential problems with active implementation efforts, and (4) measurement and evaluation of results. By incorporating clinical guideline development into a quality improvement model and integrating such efforts with a total quality management strategy, we can substantially increase the likelihood of successfully implementing clinical practice guidelines and improving the quality of care that we deliver.

Clinical practice guidelines at an HMO: development and implementation in a quality improvement model.

Harvard Community Health Plan (HCHP) is adapting to clinical medicine the managerial principles and methods of quality improvement theory that were originally developed and successfully applied in industrial settings. An essential step in applying the quality improvement cycle to clinical medicine is the setting of standards or specifications for clinical care. HCHP has chosen to focus its standard-setting efforts on the development of clinical algorithms, which provide an excellent basis for specifying and communicating optimal care processes and for evaluating actual clinical care. When implemented effectively, clinical algorithms may improve quality and decrease costs by guiding clinicians toward more standardized, high-quality, cost-effective clinical strategies and by facilitating more valid measurement of clinical process and outcomes. This article describes the evolution, structure, methods, and future agenda of the Algorithm Based Clinical Quality Improvement Process (ABCQIP) at HCHP.

Lengths of stay of patients with uncomplicated acute myocardial infarction at three Boston hospitals: impact of pre-discharge tactics.

Variability in length of stay (LOS) and its determinants were studied in 60 patients without complications after acute myocardial infarction (AMI) at three teaching hospitals. The patients at the three hospitals had similar clinical presentations and in-hospital courses. However, 81% of patients admitted to the intensive care unit (ICU) at one hospital were transferred to lower levels of care within 48 hours, compared with 40% and 56% at the other two hospitals (p less than 0.05). Patients who underwent pre-discharge exercise tests (ETT) had a longer total LOS than patients who did not (11.9 +/- 4.3 vs 9.2 +/- 2.9 days; p less than 0.01). Similarly, patients who underwent 24-hour ambulatory monitoring (AMB-MON) had a longer total LOS than patients who did not (12.3 +/- 4.3 vs 9.1 +/- 2.8 days; p less than 0.001). No differences in clinical characteristics or in survival at six months were detected between patients who did and did not undergo ETT or AMB-MON. Total LOS correlated with whether patients underwent 0, 1, or both of these tests (p less than 0.0001); each test was associated with a 2.3-day increase in the duration of hospitalization. The authors conclude that such tests may prolong total LOS of patients without complications after AMI.

Glaucoma screening. A cost-effectiveness analysis.

We designed an intricate model of the process of glaucoma screening, diagnosis, and treatment in order to evaluate the medical care costs of such efforts in relation to the benefits in terms of quality-adjusted years of vision saved, utilizing the economic principles of cost-effectiveness analysis. Although a relatively limited data base and numerous assumptions concerning the accuracy of diagnostic tests, the natural history of ocular hypertension and glaucoma, and the effectiveness of available treatment modalities, limit our ability to draw definitive conclusions concerning the cost-effectiveness of various glaucoma screening options, our analysis indicates that glaucoma screening is probably cost-effective when targeted at certain subgroups of the population. Our analysis suggests that changes in several aspects of existing screening policies may be appropriate if cost-effectiveness is to be used as one of the criteria for the efficient allocation of resources to and within screening programs. Specifically, combinations of screening tests and screening targeted at high risk populations such as blacks, diabetics, and relatives of glaucoma patients are probably more cost-effective than screening of the general population with a single test. In younger populations, the importance of detecting ocular hypertension argues for the use of tonometry. Ophthalmoscopy may be more cost-effective in older age groups in whom the higher prevalence of glaucoma outweighs the need for identifying ocular hypertensives. In the very elderly, automated perimetry becomes cost-effective since the detection of established field loss will have greater yield. In addition, it is evident that diversion of resources away from actual screening efforts and towards efforts aimed at improving follow-up and compliance would be an additional cost-effective strategy.