Preferred Practice Patterns

Abstract

In 1989 the American Medical Association (AMA) formulated the concept of practice parameters and defined them as "strategies for patient management, to assist physicians in clinical decision-making." 1 In the United States this has become a massive joint effort, involving almost 100 medical organizations.By 1995 approximately 1800 practice parameters had appeared.Other labels now in use include standard clinical protocols, pathways, algorithms, practice guidelines, and care paths.The American Academy of Ophthalmol ogy (AAO) uses the terms preferred practice patterns (PPPs) to refer to major subdivisions of eye care and ophthalmic procedure assessments (OPAs) to denote specific interventions.Although intended to help physicians enhance the quality of medical and surgical care, PPPs and OPAs are also open to use by nonphysician organizations for such purposes as streamlining medical care, reducing cost, improving communication between medical team members, meeting regulatory requirements, and ensuring the essential components of care.Thus, the federal government, insurance companies, managed care organizations, and attorneys use these documents for their own purposes, which may or may not be advantageous for patients and physicians.There is some physician resistance to PPPs that stems from indifference, traditional opposition to medical practice regulation, and increased concern regarding medical-legal liability.This concern seems justified by a recent Wall Street Journal article based in part on a study by the Harvard School of Public Health.This article states that prosecuting attorneys use practice parameters three times more often than does the defense. 2 • 3 A physician-directed section within the AAO is now coordinating the preparation of PPPs with the goal of ensuring that recommendations are based on scientific evidence.We support these efforts because the AAO follows a demanding health services research protocol. 4When claims cannot be scientifically substantiated, "consensus methods" are used.This is a recognized practice in health services circles.Most important, all AAO PPPs have a clear disclaimer delineating the limitations of each guideline.We support these qualifying statements because our main concern in this editorial is inappropriate implementation of PPPs.The PPP for diabetic retinopathy 5 is an example of a practice pattern based on well-designed experimental studies that present clear-cut benefits of compliance with screening guidelines and management recommenda tions directed toward the prevention of visual loss.These studies include the Diabetic Retinopathy Study, the Early Treatment Diabetic Retinopathy Study, the Diabetic Vitrectomy Study, and the Diabetes Control and Complications Trial.Unfortunately, not all diseases are as well studied and documented as diabetic retinopathy.An example of a PPP being carefully evaluated is YAG laser capsulotomy after cataract surgery.This procedure is currently under intensive study by the Oklahoma Foundation for Medical Quality.It is a high volume, high-cost, high-interest, and occasionally problematic procedure.The incidence of retinal detachment is thought to be slightly increased by YAG laser capsulotomy, so unwarranted capsulotomies lead to increased cost and possible visual loss.The practice pattern resulting from this study will suggest a management strategy for the application of laser capsulotomy after cataract surgery.Of all the issues raised by PPPs, we consider implementation and compliance with PPPs the most important.In a persuasive article, Woolf suggests enforcing only well chosen guidelines that accurately define optimal care. 6Before enforcement, it should be demonstrated that lack of compliance adversely affects patients.Besides basing recommendations on the best available data, we should demand that authors titrate the level of compliance requested against existing and future knowledge of the actual impact of such compliance on patient outcomes.A recent article in Ophthalmology urged compliance with the AAO's PPP for open-angle glaucoma. 7The authors note that academic ophthalmologists had a relatively high rate of conformance compared with private practitioners.Among other issues, they found 37.8% of private patients did not have a sketch or drawing made of their optic disc in the chart after the initial visit.The authors stressed the importance of documenting disc appearance and other glaucoma guidelines and argue for an "electronic medical record system or utilization/quality monitoring approach.''While we endorse electronic methods for gathering patient informa