Impact of Guidelines on Healthcare from the Patient and Payor Perspective

Abstract

Clinical practice relies on structured learning that is applied to a patient care setting. Patients present with symptoms and providers try to fit these complaints into known disease categories. Providers depend on memorized algorithms to direct diagnosis and treatment. Well thought-out guidelines developed by professional societies and based on the best available evidence have become the standard in modern medical care. Guidelines are developed to assist practitioners in making appropriate healthcare decisions, to help standardize medical care and improve quality. Guidelines attempt to change practice behavior towards an established norm when evidence is available or toward a consensus opinion when randomized trials are lacking. Patients seeking medical care expect that their practitioner is providing up-to-date, quality medical care. The payors of this care are also interested in quality but must pay attention to medical costs. Both the patient and the payor are invested in providers who use the best available evidence in providing care that is clearly based on guideline development and dissemination.

The American Pain Society (APS) has written three practice guidelines, the most recent of which is the Guideline for the Management of Pain in Osteoarthritis, Rheumatoid Arthritis, and Juvenile Chronic Arthritis, published in 2002. Based on high quality research, when available, and consensus opinion from opinion leaders, these guidelines are endorsed throughout the world’s medical community. Like any other guidelines, the goal is to standardize care and improve quality.

The future will bring more development of guidelines like those from the APS. As studies improve and trials show more effective treatment paradigms, well researched, appropriately designed guidelines will emerge which are structured for busy practices. But this will not be enough; providers need to be made aware of the guidelines, educated on their use, shown appropriate studies documenting efficacy, given simple strategies to implement these guidelines, repeatedly reminded of the appropriate care and, finally, monitored for compliance. For guidelines to be effective they must be tested, disseminated, and their impact on healthcare outcomes must be assessed.

Payors want evidence of the value for their expenditures and guidance by professional societies in allocating limited resources. At the same time, payors are struggling with quality issues. Guidelines can help standardize care that may also be more cost effective as well as satisfy quality concerns from regulatory agencies and the public. Understanding where guidelines make an impact and why resistance develops to well meaning, expert based documents will help us in our disease management efforts.