This episode demystifies clinical medical care ‘best practices’ — clinical guidelines & outcome measures. These are regularly created, validated & updated, by expert teams and organizations. This rigorous, evidence-based process provides the USA with a quality and up-to-date clinical health care system.
John L. Gore, M.D. Professor of Urology, Professor of Surgery, Health Services Researcher, University of Washington. Urologist, surgeon, clinician, researcher, educator, and expert in clinical care guidelines and outcomes. Dr. Gore is the PI of a large pragmatic trial in bladder cancer, and a quality of care expert. He previously served as the American Urological Association (AUA) representative to the National Quality Forum, which endorses national health care performance measures, and has been on guidelines panels for the National Comprehensive Cancer Network (NCCN) for kidney cancer, and the AUA for bladder cancer.
During This Episode We Discuss:
- Clinical Outcome or Performance measures are what should be practiced most of the time, based on the best available evidence to date. They are specific and rigorous. For example, Anyone over 50 yrs of age should be strongly considered for a covid vaccination booster (assuming they have received the initial dose(s)).
- Clinical Guidelines are ‘best practices’ for a given medical issue; based on the best available evidence to date. Guidelines can include a range of options and can be broad in scope. Most guidelines will rate the strength of the recommendation. An example of a clinical guideline: Of the vaccines available for COVID, vetted options include Pfizer, Moderna, et cetera.
- Guidelines can and should be used by patients as well as doctors. Most Guidelines for medical issues are available to the public. Here is a link to the American Urological Association’s clinical care guidelines.
- Clinical care follows the evidence. Guidelines and performance measures are based on rigorously collected, evaluated, and validated evidence.
- Evaluation of clinical care considers structure (for example, what kinds of medical technology are available at hospitals in a given location), process (for example, decision making, including with patient), and outcomes (for example, response to surgery or a cancer drug). (See Avedis Donabedian link in Resources below)
- Clinical care improves via many avenues. Pre- and post-surgery checklists are now routine clinical care processes but were originally inspired by pre and post-flight checklists. They have since been validated with strong evidence as significantly improving patient health care.
- Clinical care best practices aim to guide care providers, health care payers, and patients. Patients can ask their doctors “What do the guidelines say I should do, as a patient with x condition?”
- Clinical care guidelines necessarily evolve as science advances, with new drugs, treatments, and methods becoming available.
- One challenge with creating and using Guidelines and Performance Measures is that “A lot of these performance measures and guideline statements are based on evidence that may not be reflective of the patients we see in our practice every day…..and we do have to think outside of the box and have some flexibility in the care that we provide.” (Dr. Gore)
—“We’re talking about the ways we prescribe (health) care, based on our best available evidence.”
—“The process by which you come up with the (quality/outcome/performance) measures is a pretty rigorous process…”
—“When we talk about using “evidence-based medicine” we’re partially referring to the fact that we use outcomes” as evidence for guidelines.
—“One of the problems with performance measures, clinical measures, and guidelines is that the evidence changes. The treatments change, and so the guidelines have to change with them.”
— Guidelines evolve because “Good science is not frozen, it is fluid and dynamic and it adjusts as more information is known.”
—“A lot of these performance measures and guideline statements are based on evidence that may not be reflective of the patients we see in our practice every day…..and we do have to think outside of the box and have some flexibility in the care that we provide.”
—Patients can ask their doctor “What do the Guidelines say I should do as a patient with this (particular health issue)?”
- Avedis Donabedian — the author of a classic core framework for evaluating the quality of medical care, laid out 50 years ago; the basis of our system today. This link is to a recent article about Donabedian and his work and is helpful for understanding how and why outcome measures and clinical guidelines are needed and beneficial for quality health care.
- American Urological Association (AUA) Guidelines for Urology Care — find current health care guidelines for prostate conditions, bladder cancer, erectile dysfunction, etc.
- National Quality Forum (NQF)— a nonprofit US organization that sets standards for quality health care, and provides other services that advance quality health care.
- National Committee for Quality Assurance (NCQA)— a nonprofit US organization that works to improve health care quality through the administration of evidence-based standards, measures, programs, and accreditation.
- Agency for Health Care Research and Quality (AHRQ) — the lead US Federal agency charged with improving the safety and quality of healthcare for all Americans. AHRQ develops the knowledge, tools, and data needed to improve the healthcare system and help consumers, healthcare professionals, and policymakers make informed health decisions