Preferred Practice Patterns

Guest Editorial Preferred Practice Patterns In 1989 the American Medical Association (AMA) formulated the concept of practice parameters and defined 1 them as "strategies for patient management, to assist physicians in clinical decision-making." In the United States this has become a massive joint effort, involving almost 100 medical organizations. By 1995 approximately 1800 practice parameters had appeared. Other labels now in use include standard clinical protocols, pathways, algorithms, practice guidelines, and care paths. The American Academy of Ophthalmol­ ogy (AAO) uses the terms preferred practice patterns (PPPs) to refer to major subdivisions of eye care and ophthalmic procedure assessments (OPAs) to denote specific interventions. Although intended to help physicians enhance the quality of medical and surgical care, PPPs and OPAs are also open to use by nonphysician organizations for such purposes as streamlining medical care, reducing cost, improving communication between medical team members, meeting regulatory requirements, and ensuring the essential components of care. Thus, the federal government, insurance companies, managed care organizations, and attorneys use these documents for their own purposes, which may or may not be advantageous for patients and physicians. There is some physician resistance to PPPs that stems from indifference, traditional opposition to medical practice regulation, and increased concern regarding medical-legal liability. This concern seems justified by a recent Wall Street Journal article based in part on a study by the Harvard School of Public Health. This article states that prosecuting attorneys use practice parameters three times more often than does the defense. 2·3 A physician-directed section within the AAO is now coordinating the preparation of PPPs with the goal of ensuring that recommendations are based on scientific evidence. We support these efforts because the AAO 4 follows a demanding health services research protocol. When claims cannot be scientifically substantiated, "consensus methods" are used. This is a recognized practice in health services circles. Most important, all AAO PPPs have a clear disclaimer delineating the limitations of each guideline. We support these qualifying statements because our main concern in this editorial is inappropriate implementation of PPPs. The PPP for diabetic retinopathy 5 is an example of a practice pattern based on well-designed experimental studies that present clear-cut benefits of compliance with screening guidelines and management recommenda­ tions directed toward the prevention of visual loss. These studies include the Diabetic Retinopathy Study, the Early Treatment Diabetic Retinopathy Study, the Diabetic Vitrectomy Study, and the Diabetes Control and Complications Trial. Unfortunately, not all diseases are as well studied and documented as diabetic retinopathy. An example of a PPP being carefully evaluated is YAG laser capsulotomy after cataract surgery. This procedure is currently under intensive study by the Oklahoma Foundation for Medical Quality. It is a high­ volume, high-cost, high-interest, and occasionally problematic procedure. The incidence of retinal detachment is thought to be slightly increased by YAG laser capsulotomy, so unwarranted capsulotomies lead to increased cost and possible visual loss. The practice pattern resulting from this study will suggest a management strategy for the application of laser capsulotomy after cataract surgery. Of all the issues raised by PPPs, we consider implementation and compliance with PPPs the most important. a In persuasive article, Woolf suggests enforcing only well chosen guidelines that accurately define optimal care. 6 Before enforcement, it should be demonstrated that lack of compliance adversely affects patients. Besides basing recommendations on the best available data, we should demand that authors titrate the level of compliance requested against existing and future knowledge of the actual impact of such compliance on patient outcomes. 7 A recent article in Ophthalmology urged compliance with the AAO's PPP for open-angle glaucoma. The authors note that academic ophthalmologists had a relatively high rate of conformance compared with private practitioners. Among other issues, they found 37.8% of private patients did not have a sketch or drawing made of their optic disc in the chart after the initial visit. The authors stressed the importance of documenting disc appearance and other glaucoma guidelines and argue for an "electronic medical record system or utilization/quality monitoring approach.'' While we endorse electronic methods for gathering patient informa­

1987

Ophthalmology

Volume 103, Number 12, December 1996

tion to provide better data, we need evidence that pictorial representation of the optic disc prevents or protects against visual loss, and evidence that failure to follow other guidelines for open-angle glaucoma adversely affects patients. In another article in Ophthalmology, the principle of practice patterns is endorsed without reservation along with concepts such as "economic efficiency," "physician productivity," "electronic data systems," "credentialing of physicians," and "utilization rates," 8 without specifying how the recommendations of the study, when implemented, will affect the patient or the physician. The authors conclude that the information presented seeks to deliver services at a reduced cost to ''help our patients and maintain credibility with government and third party payers.'' Do we really know how reduced costs will be apportioned among patients, insurance companies, and the government? Socioeconomic articles such as the ones cited are timely and contain important issues for ophthalmologists. These reports, however, pose legal, ethical, and practical problems with which many of us are ill-equipped to deal. Some of us are somewhat uncomfortable with the implications of these articles, which are appearing in increasing numbers in our clinical journals, mixed in with other articles. It is difficult to evaluate them with the same standards used for conventional scientific articles because the articles in question often do not follow rigorous methods of health services research. Urging compliance with practice guidelines that do not target specific clinical problems may increase managed care regulation, expose the physician to unjust criticism, and increase malpractice liability. The treatment of open­ angle glaucoma, for instance, should allow for individual patient and physician variations and not require strict compliance. Most importantly, we must protect patients from overly rigid rules of practice. Physicians are the most scrutinized and regulated of any professional group, with oversight by government agencies, insurance companies, peers, and managed care organizations. Physician committees are busy creating a profusion of practice guidelines in an effort to improve the quality of medical care. The Wall Street Journal article cited above demonstrates one way physician-generated PPPs can present a serious problem for physicians. Even if PPPs and OPAs are carefully and accurately constructed, they must be applied with due attention to their purposes and limitations. Management recommendations, wherever possible, should be based on solid scientific data. If good data are not available to justify diagnostic or therapeutic recommendations, PPPs should clearly indicate that this is so. We should encourage further health services research to address these shortcomings. Preferred practice patterns, generated by the AAO carefully state their limitations and shield the physician from inappropriate outside control and liability, provided we use them with due care. As stated by the AMA, practice parameters were established to assist physicians in improving the quality of patient care, not to complicate the practice of medicine. Eventually, we may achieve the goal of this process, when our management strategies are driven by valid outcome data. In the meantime, while the concept of PPPs and OPAs is evolving, let's make sure their implementation is in the best interest of our patients, and ourselves! References 1. Department of Practice Parameters, American Medical Association. Directory of Practice Parameters: Titles, Sources, and Updates. Chicago, IL: American Medical Association, 1995. 2. Felsenthal E. Doctors' own guidelines hurt them in court. The Wall Street Journal. 1994 Oct 19; Sect B:1(W)(E). 3. Hyams AL, Shapiro DW, Brennan TA. Practice guidelines and malpractice litigation: an early retrospective. Journal of Health Politics, Policy and Law 1996;21:289-314. 4. American Academy of Ophthalmology. Development Process Phase II: Development of Clinical Content. Preferred Practice Pattern. San Francisco, CA: American Academy of Ophthalmology, 1996. 5. American Academy of Ophthalmology. Diabetic Retinopathy. Preferred Practice Pattern. San Francisco, CA: Ameri­ can Academy of Ophthalmology, 1993. 6. Woolf SH. Practice guidelines: a new reality in medicine III: impact on patient care. Arch Intern Med 1993; 153:2646­ 55. 7. Hertzog LH, Albrecht KG, LaBree L, Lee PP. Glaucoma care and conformance with preferred practice patterns: examination of the private community-based ophthalmologist. Ophthalmology 1996; 103:1009-13. 8. Bartamian M, Meyer DR. Site of service, anesthesia, and postoperative practice patterns for oculoplastic and orbital surgeries. Ophthalmology 1996; 103:1628-33. ROBERT

P.

G.

SMALL,

MD

LLOYD HILDEBRAND,

MD

Oklahoma City, Oklahoma

1988