Evidence is said to be the new bright star of health care. A growing chorus of voices is thus calling for physicians and other health care practitioners to follow evidence-based medicine (EBM), or so-called “best practices.” To practice EBM, supporters say physicians must follow evidence-based clinical practice guidelines.
Despite being painted as scientifically sound, there are more than a few detractors of EBM, including physicians, patients, and researchers. Even those who sup-port evidence-based medicine and practice guidelines worry about how it may play out in real-life patient care.
This paper will introduce the concepts, note the assertions of supporters, highlight the concerns of critics, question the emphasis on evidence and clinical guide-lines for the practice of medicine, identify the costs of guidelines, and show how EBM is making its way into state and federal laws, including medical malpractice reform initiatives. A word about terminology: this re-port uses “guidelines,” “best practices,” “ algorithms,” and “protocols” interchangeably.
Introduction
Clinical practice guidelines are the embodiment of evidence-based medicine.1 Managed care organizations began developing guidelines in the 1990s to identify inappropriate medical care and reduce unnecessary utilization of services.2 More recently, state and federal policy makers have incorporated “best practices” or evidence-based guidelines in legislative proposals aimed at health care cost containment and medical malpractice reform.3
Practice guidelines “specify the processes of diagnosing and treating particular conditions.” 4 Or as defined by the Institute of Medicine (IOM), the federally-funded organization providing the U.S. Congress with health care policy research, “evidence-based guidelines” are:
Consensus approaches for handling recurring health management problems aimed at reducing practice variability and improving health outcomes. Guideline development emphasizes using clear evidence from the existing literature, rather than expert opinion alone, as the basis for advisory materials.5
Proponents of EBM argue that “there are no systems in place for ensuring that best practices are consistently implemented.” 6 They claim that physician compliance with guidelines—essentially, practice directives—will reduce “overuse,” “underuse,” and “misuse” of health care services7 8 9 (considered by IOM to be the primary quality problems in American health care today 10 ).
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