American Journal of Law & Medicine

Broadcasting clinical guidelines on the Internet: will physicians tune in?

I. INTRODUCTION

Modern American medicine is far from ideal. Physicians practice by roles learned in medical school, rules often based on anecdotes or untested hypotheses. Medical opinion leaders shape practice by their own experience even though anecdotes are no substitute for clinical studies. Pressures to diagnose and treat come from pharmaceutical companies, equipment manufacturers, hospitals and managed care organizations (MCOs). The end result is often too much medicine or too little, but rarely the appropriate amount. Patients can end up suffering iatrogenic effects of infections picked up during hospital stays, complications from surgery or drug side effects or "cascade effects" that occur when several interventions fail in succession.(l)

In many areas of medicine, information regarding appropriate practice is missing or incomplete.(2) Research on appropriateness indicates that from one-quarter to one-third of medical services may be of no value to patients.(3) One 1988 study concluded that 21% of pediatric hospital use is medically inappropriate.(4) Other studies have found that between 20 and 40% of hospital ancillary services are unnecessary.(5) For example, carotid enterectomies, procedures that remove clots in arteries leading to the brain, were judged as appropriate in only 35% of the cases surveyed.(6) In one study, researchers looked at implantation of permanent cardiac pacemakers in a large population.(7) They found that 44% of the implants were properly indicated, that 36% were possibly indicated and that 20% were not indicated.(8) Seventy-three percent of the hospitals had an incidence of 10% or more unwarranted implantations, regardless of hospital.(9) A recent review of the research literature concluded:

 
   there are large gaps between the care people should receive and the care 
   they do receive. This is true for all three types of care-- preventive, 
   acute and chronic--whether one goes for a check-up, a sore throat, or 
   diabetic care. It is true whether one looks at overuse or underuse. It is 
   true in different types of health care facilities and for different types 
   of health insurance. It is true for all age groups, from children to the 
   elderly. And it is true whether one is looking at the whole country or a 
   single city.(10) 

Surgery is performed on those who do not need it and not performed on those who do;(11) medications are prescribed inappropriately or not used when an informed physician should use them;(12) prevention is not offered when it will save future pain and suffering.(13) Much medical care simply does not meet professional standards.(14) As Mark Schuster et al. write, "[a] large part of our quality problem is the amount of inappropriate care provided in this country."(15) They estimate that about 50% of people receive recommended care, 70% receive recommended acute care and 30% receive contraindicated acute care.(16) For chronic conditions, about 60% got recommended care and 20% contraindicated care.(17) Neither has the debate over the benefits of fee for service (FFS) versus managed care plans been productive. Studies have found little meaningful difference in quality or outcome, and quality was often disappointingly poor for both FFS and health maintenance organizations (HMOs).(18)

What can one make of these contradictory and discouraging observations? This Article argues that a major source of improvement of medical practice will be the dissemination and proliferation of clinical practice guidelines on the Internet. Such guidelines provide physicians with access to authoritative sources grounded in solid clinical research.(19) If physicians can be induced to notice and alter practice to reflect these guidelines, the practice of medicine will improve. The use of Internet websites to provide easy and friendly access to practice guidelines and other sources of medical information will have at least two effects: such access (1) will promote ready adoption of evidence-based guidelines by larger numbers of physicians; and (2) will give patients the opportunity to cross-check specific standards of care and where gray areas exist in diagnosis and practice.(20)

This Article will examine the forces that lead to physician resistance to the use of clinical practice guidelines. Part II looks at the problem of medical practice variation and its possible causes. Part III discusses the benefits of clinical practice guidelines in promoting convergence of practice and in forcing improvements in the delivery of health care. Part IV looks at the forces that make physicians resistant to change and suggests some possible sources for reducing the resistance. Part V examines some current Internet databases that facilitate easy access by health care providers to current evidence-based medicine and practice guidelines. This Article concludes by suggesting that the proliferation of user-friendly websites, combined with increasing pressure from employers and accrediting bodies, will lead to an increase by physicians in their access to and reliance on clinical practice guidelines.

II. VARIATION AND THE PRACTICE OF MEDICINE

American medicine is subject to too much variation in practice. John Wennberg and Allan Gittelsohn's early observations about medical practice variation(21) continue to be confirmed twenty-five years later. A recent study of variation in the treatment of acute myocardial infarction found that striking variability occurred within the same state or region, with most variation related to local clinical practices.(22) Acute myocardial infarction can be treated best by adherence to well-accepted practice guidelines, and yet significant percentages of patients failed to receive aspirin, [Beta]-blockers or angiotensin-converting enzyme inhibitors during hospitalization or at discharge.(23) Earlier studies had reached similar conclusions.(24)

For various reasons, physicians often ignore emerging research literature or practice guidelines on good practices. Medical practice variation is both physician-specific and institution-specific. A 1997 report by the National Committee for Quality Assurance (NCQA), based on a survey of more that 330 HMOs covering forty-five million Americans representing 75% percent of HMO enrollees,(25) found substantial variation among HMOs on several indicators.(26) The study looked at data provided by the Health Plan Employer Data and Information Set (HEDIS),(27) including measures such as [Beta]-blocker treatment, breast cancer screening, cervical cancer screening, cesarean section rates, childhood immunizations, diabetic eye exams and first trimester prenatal care.(28) The study found, for example, that heart attack patients in some health plans were treated with [Beta]-blockers less than 55% of the time, but patients in the best performing plans received [Beta]-blocker treatment more than 90% of the time.(29) Similar variations were found for the other indicators.(30) Physicians often ignore emerging research literature or practice guidelines on good practices. The variation in practice that results produces poor quality health care. Money is wasted on unnecessary treatments, patients are exposed to excess risk and some patients fail to improve or even die because of failure to receive appropriate care.(31)

A. FAILURES TO KEEP UP

Too much medicine is practiced by physicians in isolation from intensive peer contact and institutional scrutiny. The solitary virtuoso physician is not the ideal health care professional, although he or she is often idealized in discussions of medical practice.(32) Practicing in isolation often means that the physician is out of touch with current developments,(33) lacks the financial resources to provide sophisticated procedures for patients(34) or too easily escapes peer pressure and censure.(35) The ideal physician works within institutions, supported by current data and research, medical staff and modern technology. Such a physician must not only possess the skills of a sophisticated technician, but also should be able to apply specialized scientific knowledge.(36) Standardization of medical education, training and practice is the source of good patient outcomes over time.(37) A physician earns a degree based on standardized and highly scientific education, takes standardized medical boards and specialty tests and thereafter attends continuing medical education (CME) and periodic recertification courses. Most professional medical training and education concentrates on eliminating marginal, unproven and incompetent physicians through uniform institutional processes. Although physicians develop substantial clinical experience with hundreds of patients, this anecdotal experience does not necessarily lead to valid practices. As Gary Belkin comments, "it is about time that someone begins minding the store, hemming in profligate clinical hypothesizing and watching the bottom line through clearly known rules and assumptions."(38) Clinical practice guidelines, disease management and other managed care techniques offer "some order and logic to a medical practice in which potentially dangerous and risky procedures were advocated on little more than anecdote and fashion."(39) Guiding physicians in practice through standardized guidelines allows them to practice better medicine.

B. EXTERNAL INCENTIVES TO TREAT

Physicians wield immense power in the health care industry: they direct other health professionals and authorize the purchase of billions of dollars in health care commodities.(40) Physician expertise dictates that they head medical teams, which are imbedded in an increasingly complex medical delivery system that integrates allied health professionals, pharmacists, drug companies and others.(41) Corporate bureaucracy must combine with physicians' technical virtuosity to manage rapidly proliferating information and treatment complexity.

Physicians direct the expenditure of about 70% of the money spent on health care, even though their compensation is only about 22% of those expenditures.(42) Patients, on the other hand, are generally poor consumers of health care. Patients cannot effectively assess doctors or choose medical care facilities because no central information resource exists to assess the competence and integrity of doctors and their advice.(43) With over 650,000 physicians(44) and the decentralized health care market structure, provider evaluations are very difficult to carry out. However, where evaluations are conducted, providers resist disclosure of this information for good reasons.(45) As the gathering of performance data on physician and health plans improves, it is possible that consumers and employers will choose doctors and plans based on such data.(46)

Doctors recognize few ironclad rules when practicing medicine. This means that substantial variations will occur in the treatment of patients, even when differences are held constant.(47) These tendencies are reinforced because physicians may pressure patients to consume a variety of ancillary services.(48) Similarly, hospitals and other provider arrangements, such as MCOs, are creating and marketing products for potential but previously unaddressed services. Such services include wellness programs and sports medicine for those who are generally not defined as ill. …

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