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Clinical Guidelines & the Ethics of Comparative Effectiveness

In today’s post to his always-excellent blog Managed Care Matters, Joe Paduda writes about the ethics of clinical guidelines and the dilemma of comparative effectiveness.

He rightly says that… “If we are to solve the access and cost problem, payers, providers, and patients must be comfortable with the decision process and methodology.”

And he goes on to talk about the challenges among all stakeholders of using treatment guidelines, when each case is different. Read his post here.

Here is a copy of my response, which I posted on Joe’s blog today…

Joe, I’m president of guidelines for Reed Group (www.reedgroup.com), a leader in the field of absence management. We develop and publish the industry-standard return-to-work guidelines, and have a partnership with the American College of Occupational and Environmental Medicine to integrate evidence-based treatment guidelines. (www.mdguidelines.com)

You talk about one of the classic issues in medical publishing, which is the apparent conflict between the “art” and “science” of practicing. Presumably, if enough quality information were available (and in a usable format), the “art” could be displaced in favor of the “science”. Making that practical, while aligning with the incentives that drive physician behavior, is obviously an immense challenge.

At MDGuidelines, we have taken a huge step by making outcomes (statistics) the fundamental basis for our recommendations. We believe that data speaks louder than experts, and we put this into practice via some very innovative tools. Our predictive model actually allows physicians to “drill down” into the outcomes data to see what effect co-morbidities are likely to have on recovery times. At the same time, our world-class Medical Advisory Board layers clinical wisdom on top of the data to provide appropriate insight and corroboration.

We also have a vibrant integration model in our business. We realize that the best way for content to be utilized is via “decision support” — meaning that the information is available in the physician’s workflow in an unobtrusive but persistent way. We are working with major electronic medical records providers in anticipation that this is the way most medical content will be utilized in the future. Importantly, too, our integration relationships allow us to collect outcomes for ongoing development of the guidelines.

We believe that occupational health is dramatically outside the mainstream in modern medical practice. Physicians are very poorly trained in the “work” part of the work/life balance and as such, often fail to consider the critical importance of the patient’s productivity to their health. At MDGuidelines, we consider return-to-work to be a proxy for quality health care delivery in general. When a patient is too sick to work, that is the beginning of a health care episode. When she is healthy enough to return to work, then there is a positive outcome marking the end of the episode. Anyone interested in the “big picture” of measuring outcomes in health care should take a strong interest in return-to-work data.

Finally, the ethical issues around use of clinical guidelines can only be resolved with the understanding that all of the stakeholders need to have access to the same information. We believe this leads to more consistent and responsible care and better outcomes. We continuously promote the notion that our guidelines should be used as a communication tool between physician, employer, insurer, and patient. This allows for a more transparent and better-planned recovery process where “hidden agendas” and one-sided interests and incentives can be minimized, and the physician-patient relationship can be emphasized. In the era of the internet, this collaborative approach to outcomes-driven medicine is realistically within reach.

– Jon Seymour, M.D., Reed Group President, Guidelines


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