February 2014, Vol 3, No 1

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Hematologists Question Panel About Guidelines and Performance Measures


Hematologists Question Panel About Guidelines and Performance Measures

At a special symposium on quality and clinical practice guidelines during ASH, guideline developers fielded questions from hematologists. Panelists included Holger Schünemann, MD, PhD, of McMaster University in Hamilton, Canada, an expert in guideline development; and Lee H. Schwamm, MD, executive vice chair of neurology at Massachusetts General Hospital, Boston, MA, who chairs the Get With The Guidelines – Stroke clinical work group. Following are some of those exchanges.

How do you keep guidelines up to date?

Dr Schwamm This is a tremendous challenge. We need to be with the guidelines, not ahead of them. Randomized controlled trials need to be digested and reviewed, and systematic processes applied. This means a professional commitment by members of our societies to engage in guideline updates and review and to shorten the cycle it takes to produce quality guidelines.

With changes in the US healthcare system, and with constrained resources, how do we incorporate cost-effectiveness into guidelines?
Dr Schwamm
We often think of resources as being about the cost of drugs. But societal costs are also significant, and the patient is bearing an increasing proportion of the burden. Shifting care from inpatient to outpatient settings may save hospitals money, but it increases the patient burden dramatically. The conversation ultimately occurs with the patient at the bedside, and this conversation should include understanding what the therapy will cost the patient. Adherence will be greater when treatment is presented in the context of what the patient can afford.

Dr SchünemannThe answer is that resources need to be invested in order to determine which resources need to be expended. We must have adequately trained individuals supporting the guideline development process.

Recent studies point to the failure of electronic medical records (EMRs) to provide benefits and suggest that EMRs are huge decrements to physician productivity. It has been reported that physicians spend 12% of their time with patients and 50% on documentation to meet meaningful use requirements. Much of this information is likely to be specious. How will this affect guideline development?

Dr Schwamm EMR is the promise of the future and also the disruption of our practices. We have a 10-year journey ahead of us to make documentation a seamless part of what we do and not the bane of our existence. Regarding quality of the information obtained, it is important to distinguish registry-based quality assurance programs from EMR-derived information. Human intervention is still needed to cull accurate information from physician records and to reconcile information found in 5 different places. We must emphasize to the regulatory bodies the necessity of having registries that do require some human intervention.

Once you move away from safety or emergency interventions, you have guidelines based on a wide distribution of expert biases and patient values – which is the reality of trying to come up with uniform guidelines. The problem is that these guidelines are linked by private and government insurers to pay-for-performance measures and the publication of “report cards.” It seems the fundamental core of the guidelines has been subverted into a means of standardizing practice that ignores disagreement among experts and ignores patient choice.

Dr Schünemann The pay-for-performance issue requires careful choice of the right recommendations. We must look for indicators that reward performance and better patient outcomes. Weak recommendations and suggestions rarely lend themselves for use as performance measures, but they can still be useful – for example, not in documenting whether an intervention was applied but whether shared decision making occurred in an informed way. Weak recommendations also lay out in a transparent way the disagreement among people who interpret the evidence. New guidelines should display this disagreement so that the physician can reflect on this with the patient and weigh the options.

Dr Schwamm It is incumbent upon professional societies to make good measures that are a compromise between the ease of collection and the value of the information. Ideally, we want every physician to know what the guidelines are and to be able to articulate why they are or are not adhering to them. It is important that the next physician to see that patient does not simply correct the first physician’s “mistake” by initiating the recommendation, but that he or she also understands the dialogue.

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