The ontological basis of strong artificial life

In 1973, the United States Congress enacted legislation requiring physicians to initiate Peer Review Organizations to monitor utilization and quality of hospital and physician services in the federally funded Medicare program. A hardly noticed provision of the statute intimated the desirability of formulating guidelines for medical treatment. What was originally intended to simplify and universalize general standards by which quality of care could be objectively measured has more recently escalated into formalized projects, subsidized by government, to create "practice parameters". The impetus to define clinical conditions and methods of treatment for specific medical conditions (practice parameters) and standards of practice to avoid or defend malpractice claims (risk management protocols) are part of the movement in the United States for tort reform. If the vague "reasonable man" standard of care in negligence law can be supplanted by a scientifically developed, particularized medical practice standard, it is anticipated that spurious claims and defensive medical practice will be discouraged, quality improved, iatrogenic injury and malpractice litigation diminished. Many U.S. states undertook tort reform in the last decade. A few have embarked on medical-legal reform. One state is conducting a five-year medical liability project that calls for the development of practice parameters and risk management protocols in four medical specialties. The parameters will have the effect of law and may be introduced as evidence in medical malpractice trials. How the parameters are established, their effect on the strategies of litigation, the resultant trial problems in the introduction of evidence and in the burden of proof and their potential for acceptance by a significant number of jurisdictions-are the issues to be explored in this paper.     

Physicians' view of practice guidelines. A survey of Italian physicians

After more than 10 years of development, two different views of practice guidelines are emerging: either as an educational tool for the medical profession, or as a forum where health care issues can be debated by physicians and non-medical groups. Physicians use practice guidelines in the former model to set their own standards of good quality care, while the latter approach needs contributions from other components in order to decide what should be provided by our health care systems. In a survey of Italian physicians' opinions and attitudes toward practice guidelines, responders supported the "narrowest" model. More than 80% stated that improvement of quality of care and reduction of variation in clinical and practice styles should be the aim of practice guidelines, without representatives from outside the medical profession being involved (61%, 79% and 86% disagreed with a possible involvement, respectively, of patients, health care administrators and representatives of the public at large). Overall, 38% of physicians had a positive attitude toward guidelines viewed as a quality assurance tool for the medical profession. Overall, physicians seem to ignore that the need to rationalize health care calls for input from other professions and members of society. Indeed, most of the issues facing medicine today are mainly a matter of how much value our societies attach to the benefit expected from the available health services. The answers as to what should be done in health care probably cannot be left to the medical profession alone.     

Practice guidelines and the practice of medicine: is it the end of clinical judgment and expertise?

Clinical practice guidelines are an increasing part of efforts to improve the quality and reduce the cost of health care. They are recommendations for the evidence-based care of average patients, not rules for all patients. At best they are developed by panels representing a wide array of expertise and experience related to the clinical question, are based on comprehensive, critical review of scientific evidence, make clear how value judgments affect recommendations, and take into account all of the issues bearing on clinical decisions, such as effectiveness, risk, convenience, cost, cost-effectiveness, and the resources needed to carry out the recommendations. Physicians have a mixed opinion of guidelines, believing they are both useful summaries to improve the quality of care and potential tools to judge and control them. Although guidelines may point out the best research evidence to guide the care of average patients, they are not a substitute for clinical judgment, which should be applied to each individual patient.     

Levels of scientific evidence and strength of clinical recommendations. From trials to guidelines. The Italian Group on Medicine Based on Evidence--(GIMBE)

Evidence-based medicine is a new paradigm of clinical practice that promotes the collection, interpretation and integration of valid, important and applicable to patients research-derived evidence, and it can improve the efficiency and the effectiveness of health care. Nevertheless research often fails to get in clinical practice, also because the traditional tools used by physicians to solve clinical problems are less reliable as the volume/complexity of medical information and biomedical technology have grown exponentially. New tools are emerging to help physicians: the systematic reviews of randomized controlled trials and the clinical practice guidelines that summarize a great volume of medical knowledge to improve health care. Practice guidelines, with a systematic review or meta-analysis pertaining to a definite health problem, summarize the evidence of clinical trials in clinical recommendation. These combine the strength and heterogeneity of the primary studies with magnitude and precision of the treatment effects as it relates to the minimal clinical benefit. The recommendation may suggest therapeutic intervention when the baseline risk is high or otherwise when the baseline risk is low. The Authors discuss principles of evidence-based medicine, measures of treatment effectiveness, systematic reviews and methods used by experts to graduate the strength of clinical recommendations in producing practice guidelines.     

The use of low-osmolar contrast agents: technological change and defensive medicine

The escalating cost of medical care in the United States, especially in the past decade, has resulted in efforts to identify the factors contributing to rising costs. One factor often assumed to cause higher medical costs is the physician's fear of liability for not using the latest available technology. In this article, we report the results of a case study we conducted to better understand the relationship between the introduction and use of one particular technology, low-osmolar contrast agents, and liability concerns. Our study suggests that both clinicians and administrators are primarily guided by the medical benefits of low-osmolar contrast agents, and that liability concerns, although widespread, are of secondary importance. The inability to control this and similar technologies is likely to put a far greater strain on the nation's health care resources than is the practice of defensive medicine. These findings may be helpful to health policy makers, physicians, administrators, and legislators considering choices for health care reform in general and for medical liability reform in particular.     

Quality management in medical specialties: the use of channels and dikes in improving health care in The Netherlands

BACKGROUND: In 1989 a Dutch national policy was instituted to ensure that quality management is the responsibility of both health care professionals and management, with input from insurers and patients. In turn, quality management of medical specialists remained to a large extent self-regulatory, with accountability toward third-party payers and patients. Three programs for quality management-peer review, guidelines, and visitation-have sufficiently persuaded patient organizations and care insurers about medical specialists' ability to ensure the quality of the care they provide. PEER REVIEW: Operational since 1976, the national program for peer review in hospitals has stressed the need for explicit evaluative mechanisms. This program led to the foundation of the National Organization for Quality Assurance in Hospitals (CBO), which conducts peer review activities but also support efforts aimed at quality assurance in hospitals. Once it is linked with the other two quality management programs, peer review will realize its full potential as a profession-based method for standardizing and rationalizing medical specialty practice. PRACTICE GUIDELINES: Since 1982, more than 60 consensus guidelines have been developed for and by medical professionals, with input from patient organizations and third-party payers. Medical specialty associations have also created their own guidelines. Although the guidelines' impact has not been evaluated systematically, studies have shown effects on behavioral change and health outcomes. Solid, credible guidelines continue to be developed, although the successful implementation of these guidelines needs to be studied. VISITATION PROGRAM: Visitation, or onsite assessment of specialty practice sites (in training and non-training hospitals), has been a hot issue in Dutch medical quality assurance. All 28 scientific societies have visitation programs, focusing on areas for improvement such as process management, use of guidelines, and evaluation of patient satisfaction and treatment outcomes. Closely linked to other medical quality assurance activities, visitation programs also incorporate clinical guidelines into evaluations. CONCLUSIONS: Profession-driven peer review, practice guidelines, and visitation programs have been effective support tools for quality management in The Netherlands. Future challenges involve creating more synergy among these programs and between the profession-based quality management approaches and recently introduced hospital-based quality systems and maintaining the trust between third-party payers and patients.     

An overview of clinical policies with implications for clinical practice, medical education, and research

Clinical policies, also known as practice parameters or practice guidelines, are gaining notoriety out of a desire to control escalating medical costs, lessen wide practice variations, and improve quality of care. The clinical policies are supposed to influence medical decision making by summarizing scientific data about a clinical problem in a format that is easily understood by patient and physician alike. Developing an evidence-based policy involves: a clearly defined clinical problem, a comprehensive literature review, a summary table of the data (known as an evidence table), a presentation of this data as outcome possibilities from alternative decisions (in the form of a balance sheet), and creation of clinical recommendations that incorporate both financial costs and patient preferences. Well-developed policies can be used by family physicians as guides in areas of clinical uncertainty and by medical educators as up-to-date literature syntheses for teaching critical appraisal and for outlining approaches to common problems. Explicit policy formulation also highlights the shortcomings of existing literature and can suggest more appropriate future research. The future of the clinical policy movement rests on its ability to reduce costs of care and improve patient outcomes. Explicit clinical policy formulation incurs significant development and implementation costs and the evidence on which many policies are based is lacking. Nevertheless, clinical policies in some form are likely to play an increasing role in medical care.     

Evidence-based medicine. How to use biomedical literature to solve clinical problems. Italian Group on Evidence-Based Medicine-GIMBE

Clinical practice is constantly changing, the rate of changing is accelerating and consequently it may even take years before the results of clinical research will be incorporated in day-to-day practice. So, there is a large gap between what the biomedical literature contains and the care that most of patients receive. The gap is widened by the extensive processing that results of clinical research require before they can be used. Evidence-based medicine is a new approach to health care promoting the collection, interpretation, and integration of valid, important and applicable research-derived evidence. The best available evidence, moderated by patient circumstances and preferences, is applied to improve the quality of clinical judgements. There are many information tools that facilitate the practice of evidence-based medicine. These include users' guides to the medical literature, strategies to improve the yield of MEDLINE searches, standardized formats for abstracts of journal articles and guidelines, new journals, systematic reviews and meta-analyses, resources on-line and software tools bringing high quality information to the point of clinical decision making. However, these tools are poorly spread and physicians lack of necessary skills for their effective utilization. In this article the authors describe guidelines for efficient and effective utilization of biomedical information tools to solve clinical problems and improve the quality and the cost/effectiveness of health care.     

Clique-detection algorithms for matching three-dimensional molecular structures

MAAGs were introduced as a result of the 1989 White Paper 'Working for Patients', with the remit to direct, coordinate and monitor medical audit activities in general practice. They were funded through the new FHSA management budget and each MAAG was responsible to its own FHSA. They were accepted as a completely new institution as a part of the introduction of an innovative management structure in a reformed NHS. When viewed in an historical context, MAAGs can actually be seen as a part of an expanding culture of greater objectivity and critical analysis which has burgeoned in medical practice over the last two decades. Although MAAGs began with an educational role with uniprofessional medical audit, they have embraced multiprofessional clinical audit in primary care in the context of the wider aspects of quality in practice. The last 20 years have seen the development of clinical guidelines, evidence-based medicine and application of business management theory to clinical quality. All these have reflected the increasing demand for explicit standards of care which has also formed the basis of clinical audit and MAAG activity. MAAGs should be seen as an inevitable concomitant of this historical trend to improve the application of scientific rigour in medical practice. With the adoption of clinical effectiveness, incorporating all these themes, as one of the NHS Executive's six medium-term priority areas, MAAGs are uniquely placed to act as agents of change to enhance the quality of primary health care.     

Spreadsheet evaluation of computerized medical records: the impact on quality, time, and money

Information and communication technologies are presumed to play a critical role in improving effectiveness and efficiency of clinical care. Although the most promising directions of technological development are microcomputer-generated computerized medical record systems, documenting their value has been a major challenge for health care providers. This paper proposes a 15-item spreadsheet instrument for evaluating computerized medical records, and demonstrates how it was experimentally applied to a 6-year long experience at three sites. In conclusion, preliminary implications and guidelines are drawn with regard to practice and research in this area.     

A peer review feedback method of promoting compliance with preventive care guidelines in a resident ambulatory care clinic

BACKGROUND: Simple distribution of clinical practice guidelines to physicians does not change practice behavior. A low-cost, continuous peer review feedback method was used to promote resident physicians' compliance with nine preventive care guidelines at the ambulatory care clinic at the Marshall University School of Medicine (Huntington, West Virginia). METHODS: Preventive care guidelines were distributed and a peer review feedback program was instituted in the resident physician primary care practice. The frequency of resident physician use of nine preventive care services was assessed and compared during three periods: preguideline (September 1, 1993, to March 1, 1994; 148 patients), guideline (September 1, 1994, to March 1, 1995; 148 patients), and one-year follow-up (September 1, 1995, to March 1, 1996; 150 patients). The patients in the three periods were similar in age, gender, and risk for influenza and pneumococcal infection. RESULTS: During the guideline period, resident physicians offered patients four preventive care services-tetanus toxoid immunization, clinical breast examination, Papanicolaou smear testing, and hemoccult testing significantly more often than during the preguideline period. All services were offered significantly more often during the one-year follow-up period compared with the preguideline period and as often as in the guideline period. CONCLUSION: A low-cost, continuous peer review feedback program significantly and durably improves resident physician compliance with clinical practice guidelines on preventive care services. However, the effectiveness of the poor review feedback method may not generalize to private practice or other settings. Research on other methods to promote compliance with clinical practice guidelines and to influence physician behavior in general should continue.     

Tertiary structural changes and iron release from human serum transferrin

Guidelines for clinical practice are intended to suggest preferable approaches to particular medical problems as established by interpretation and collation of scientifically valid research, derived from extensive review of published literature. When data are not available that will withstand objective scrutiny, a recommendation may be made based on a consensus of experts. Guidelines are intended to apply to the clinical situation for all physicians without regard to specialty. Guidelines are intended to be flexible, not necessarily indicating the only acceptable approach, and should be distinguished from standards of care that are inflexible and rarely violated. Given the wide range of choices in any health care problem, the physician should select the course best suited to the individual patient and the clinical situation presented. These guidelines are developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee. These guidelines are also approved by the governing boards of American College of Gastroenterology and Practice Parameters Committee. Expert opinion is solicited from the outset for the document. Guidelines are reviewed in depth by the committee, with participation from experienced clinicians and others in related fields. The final recommendations are based on the data available at the time of the production of the document and may be updated with pertinent scientific developments at a later time. The following guidelines are intended for adults and not for pediatric patients.     

Role of laparoscopic ultrasound in cancer management

Clinical practice guidelines have enormous potential to improve the quality of and accountability in health care. Making the most of this potential should become easier as guideline developers integrate guidelines within information systems and electronic medical records. A major barrier to such integration is the lack of computing infrastructure in many clinical settings. To successfully implement guidelines in information systems, developers must create more specific recommendations than those that have been required for traditional guidelines. Using reusable software components to create guidelines can make the development of protocols faster and less expensive. In addition, using decision models to produce guidelines enables developers to structure guideline problems systematically, to prioritize information acquisition, to develop site-specific guidelines, and to evaluate the cost-effectiveness of the explicit incorporation of patient preferences into guideline recommendations. Ongoing research provides a foundation for the use of guideline development tools that can help developers tailor guidelines appropriately to their practice settings. This article explores how medical informatics can help clinicians find, use, and create practice guidelines.     

Ventilatory care in a selection of Ontario hospitals: bigger is not necessarily better! Critical Care Research Network (CCR-Net)

OBJECTIVE: To determine whether there is variability in the structure and process of ventilatory care in intensive care units (ICUs) of the hospitals of Southwestern Ontario. DESIGN: Self-administered questionnaire-based survey. SETTING: ICUs of selected community and teaching hospitals of Southwestern Ontario. PARTICIPANTS: Head of respiratory therapy service of respective hospitals; in those hospitals without respiratory therapists, the ICU nurse manager. INTERVENTION: Self-administered questionnaire. OUTCOME MEASURE(S): The availability of different models of ventilators and respiratory therapist and physician coverage were assessed. In addition, the use of clinical practice guidelines, respiratory therapists, and the nursing role in ventilatory care were determined. RESULTS: In general, the structure of ventilatory care, including availability of different modes of ventilation, and coverage by respiratory therapists and physicians was more comprehensive in larger hospitals. However, the availability of some modes of ventilation varied more than expected among hospitals of comparable size. Similarly, variability in the process of ventilatory care, defined by the availability of clinical practice guidelines and the roles of respiratory therapists varied both within and among hospitals of different size. CONCLUSIONS: The structure and process of ventilatory care in this sample of Southwestern Ontario ICUs was found to be variable. Not all this variability could be accounted for by hospital size, suggesting a potential for improvement in overall ventilatory care. Further study is required before any specific recommendations can be considered.     

The behavioral sciences in medical education: A view from psychology.

Argues that a number of unsolved issues confront the behavioral sciences in medical education and that the most pressing problem is the type of core basic science curriculum that should be provided. The behavioral sciences often seem to fail in their teaching mission because they do not provide that information which can be "converted" into specific clinical skills. Recent studies of behavioral science programs at 9 major medical schools underscore the fact that there is no unanimity of opinion about the material that should be taught to all medical students. Although diversity is valuable because it promotes experimentation with curricula, the behavioral sciences, particularly psychology, should develop a model of the doctor's job which contains the basic information required for primary patient care. Some examples of clinically applicable behavioral science content that could be included in all curricula are suggested. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A normative analytic framework for development of practice guidelines for specific clinical populations

BACKGROUND: A central problem in practice guideline development is how to develop guidelines that appropriately account for variations in clinical populations and practice settings. Despite recognition of this problem, there is no formal mechanism for assessing what the need is for flexibility in guidelines, or for deciding how to incorporate such flexibility into recommendations. OBJECTIVE: This research sought to provide a formal basis to determine when clinical circumstances vary sufficiently that guideline recommendations should differ, how recommendations should be tailored for a specific clinical setting, and whether the benefit associated with such site-specific guidelines justifies the expense of their development. RESULTS: The authors describe an approach for estimating the maximum health benefit that developers can obtain by eliminating uncertainty about differences in the patient populations and practice settings in which a guideline will be used. This estimate, the expected value of customization, provides a mechanism to evaluate the cost-effectiveness of the development of site-specific guidelines that account explicitly for variation in clinical circumstances. Application of this method to the development of screening guidelines for human immunodeficiency virus (HIV) infection indicates that the development of site-specific guidelines potentially is cost-effective. Site-specific guidelines either improve, or leave unchanged, the efficiency of HIV screening; whether they increase or decrease total expenditures and health benefits depends on the choice of a cost-effectiveness threshold, and the clinical problem. CONCLUSIONS: Development of guideline recommendations based on decision models provides a normative approach for evaluating the need for and the cost-effectiveness of site-specific guidelines that have been tailored to specific practice settings. Such site-specific guidelines can improve substantially the expected health benefit and the economic efficiency of practice guidelines.     

Guidelines as a strategy for preserving professional autonomy

Practice guidelines are often perceived as a threat to physician autonomy. However, the true challenge to physician autonomy is the rising costs of health care, which in turn is the result of continued progress in medical research. Since, inevitably, choices must be made about how our limited resources are expended, an increasing number of physicians are concluding that health care providers should assume financial risk for providing care--so that providers can make the decisions about which interventions are used for which patients. In this context, groups of physicians are adopting practice guidelines as an important strategy for providing high quality and efficient care under capitation. At least in some areas, practice guidelines are emerging as a critical tool for physicians to assume financial risk, and thereby protect professional autonomy.     

Variations in the management of primary care: effect on cost in an HMO network

OBJECTIVE: To determine the relation to cost of different aspects of the management of primary care among group practices within a health maintenance organization network. MEASURES: A cross-sectional survey study of medical practices conducted with Blue Cross Blue Shield of Minnesota, St Paul. The subjects were group practices accepting financial and administrative responsibility for primary care services in the managed care plans of Blue Cross Blue Shield of Minnesota. One hundred twelve primary care practices and 153397 enrollees were included in this analysis. The principal resource use measure in this study was nonhospital cost per member per year estimated from payments to providers plus subscriber-eligible liability. RESULTS: The medical directors' responses revealed considerable variability in the management of primary care in these 112 practices. Group practice characteristics consistently associated with lower nonhospital cost were patient identification of a primary care physician, cost of care profiling, more frequent physician profiling, more patients per hour in the clinic, a higher proportion of primary care physicians in the specialty of family or general practice, and a greater number of physicians in the group practice. CONCLUSIONS: Results of this study demonstrate substantial variation in the management of primary care among group practices participating in a health maintenance organization network. These differences are associated with significant variation in the nonhospital cost of care for enrollees.