Can A Guideline Development Process Influence Care?

December 07, 2012

Research has demonstrated that there is variation in the adoption of disease management strategies shown to improve health-care outcomes, and that variation from the optimal strategies can lead to worse outcomes. Clinical practice guidelines were developed to disseminate knowledge of “best practices” and standardize the approach to common medical problems and reduce harmful variation. As it turns out, however, physicians are not very good at following guidelines. Among the stated or implied barriers to guideline adherence are: lack of knowledge of guidelines, desire for autonomy (eminence-based versus evidence-based practice), lack of “faith” in the guideline recommendations, and absence of meaningful incentives. The latter is being addressed in the health-care reform we are experiencing — we are no longer going to be paid solely on the volume of services we provide, but instead on the quality of work and the outcomes we achieve. 

The definition of quality and measurement of outcomes has generally been the purview of administrators; however, it is the intent of AGA to allow gastroenterologists to decide what defines quality and the metrics by which we will be judged. CMS and other payors rely upon the National Quality Forum (NQF) to validate quality measures upon which they will differentiate payment to physicians and health-care systems. The importance of the quality, quantity and consistency of the evidence recently became clear as the NQF Gastrointestinal and Genitourinary Steering Committee reviewed potential measure concepts. The committee’s discussions and questions underscored the importance of strong guidelines and rigorous guideline development processes as the foundation of measures development. 
 
To improve the validity of our guidelines and the quality measures derived from guideline recommendations, the AGA Institute recently changed the method by which clinical practice guidelines are developed, adopting the GRADE process. This internationally recognized method incorporates not only the quality of evidence supporting specific interventions, but also weighs the harms of competing strategies against the benefits, examines potential ambiguity regarding patient preferences for competing interventions, and compares resource utilization between strategies. We hope that GRADE will provide transparency to the guideline process and, coupled with the financial incentives provided by achieving benchmarks in quality measures, improve “buy-in” from physicians. 
 
The final piece of the quality puzzle is the development of resources that allow implementation of guideline recommendations into clinical practice. Clinical decision support tools will be provided concurrently with guidelines that will allow quick and easy access to recommendations through smartphone apps, tablets, laptops as well as hard-copy flow-charts. 
 
We have committed to a rigorous guideline development process based on the GRADE methodology to evaluate the quality of evidence and rate the strength of guideline recommendations. To that end, the process by which guidelines are developed can influence care. Look for additional details in the coming weeks and months.
 
— John Inadomi, MD, AGAF

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