AHRQ sends mixed message on guidelines

Report expresses concern on lowering LOS

The Agency for Healthcare Research and Quality (AHRQ), a federal agency in Rockville, MD, charged with improving the quality and safety of health care services, released new evidence July 17 that practice guidelines have the potential to significantly affect patient safety by facilitating wide-spread dissemination of practices that effectively reduce medical errors and improve care.

According to the report, it is unclear whether the costly development and implementation of clinical pathways represents an appropriate use of limited health care resources. Moreover, there is very little information on the application of pathways to patient safety. The report says there are theoretical concerns that pathways may result in adverse patient outcomes as a result of the shortened length of stay and a dependence on "cookbook medicine" but adds that there is little support for this in the literature.

The report, Making Health Care Safer: A Critical Analysis of Patient Safety Practices, reviewed evidence from a number of patient safety practices. It lists 73 that are likely to improve patient safety and describes 11 that the researchers considered "highly proven to work" but not routinely performed in the nation’s hospitals.

Researchers were surprised that more than a dozen practices long considered important by patient safety experts — including the use of computerized order-entry systems, improved hand-washing compliance, and changes in nurse- staffing ratios — have not been sufficiently studied and therefore did not make the top 11 list.

"It is well-established in other medical fields that known tenets of effective health care are not practiced on a universal basis, despite overwhelming evidence supporting their use," according to the 640-page report.

According to an audit of Medicaid charts in Connecticut, for example, only 50% of patients presenting with an acute myocardial infarction received aspirin and beta-blockers on the day of admission, despite substantial evidence that these practices reduce mortality. A second report estimated that 3,500 infarctions would be averted and 4,300 lives saved annually if beta-blockers were appropriately prescribed for patients with coronary artery disease.

The report also devotes some time to the idea that practice guidelines, if improperly developed or implemented, actually could be detrimental to the process of care or worsen clinical outcomes. For example, a study of guidelines in the use of neurodiagnostic testing in patients with low back pain found the tests were more frequently utilized in an improper fashion than at baseline when clinicians were given a set of guidelines that were relatively narrow in focus.

Another study of patients treated for congestive heart failure found the guidelines actually increased the length of stay beyond what was clinically necessary. According to the report, while neither of these studies revealed worsened patient outcomes due to the guidelines, that potential exists. "The promulgation of guidelines with imprudent advice could . . . result in widespread harm to patients," the report asserts.

The report also points out that developing and implementing practice guidelines is expensive. "When developed for a complex clinical problem by a national organization," says the report, "they consume tremendous resources, often tens of thousands of dollars."

The manner in which practice guidelines are implemented is at least as important as the content of the guidelines themselves, according to the report. It notes that several systematic reviews have concluded that the deterrents vary by practice location and that strategies to circumvent these barriers must be devised on an individual and local basis.

The report concludes that, although evidence specific to the use of patient safety guidelines is "scanty," guidelines in this area are likely to be as effective as any other. The effectiveness of guidelines depends on many factors beyond their content, the report adds. "In particular, specific attention must be focused on utilizing appropriate implementation strategies if the full potential of guidelines is to be realized."

Another section of the report concludes that there is "conflicting evidence" regarding the efficacy of critical pathways as a method to modify health care provider behavior and as a means of implementing patient safety initiatives. "Although a few studies suggest they may impact physician practice and, to a lesser extent, complication rates and other clinical outcomes, the data are inconsistent and more studies are needed," the report concludes.