Practice Guidelines Committee Develops Definitions of Term

The Academy leadership demonstrated its commitment to practice guideline development and outcomes measurement by hiring a full-time staff member devoted to these areas. The addition of the staff resource infused renewed enthusiasm into the Practice Guidelines Committee which, in turn, has generated significant activity by the Committee.

One of those activities was the development of definitions of terms related to guideline development. As the Committee discussed the types of guidelines it will be developing this next year, it became evident that definitions of the various "products" were essential.

Definitions presented here do not represent a consensus in the field, but rather represent an attempt by the Committee to describe the range of descriptions of practice "products" so that within the Academy we can be consistent in our classification of the type of "product" being referenced.

The Committee selected seven popular terms for definition: parameters, guidelines, algorithms, pathways or protocols, utilization review criteria, standards of quality, and outcome measures. The Committee acknowledged that some of these terms describe the process of care while others describe the outcomes.

Practice Parameters are documents which define, from the perspective of the health care provider, effective means of diagnosing, treating, and managing various conditions and diseases. Typically, they are based upon literature review (scientific research in the form of randomized, controlled clinical trials, reports of series, or case studies) or "expert clinical experience." They are prepared by individuals with expertise in the field.

Practice parameter is the term used by the American Medical Association for all types of "products," but the Academy's use will be limited to well-documented and researched statements supported by scientific literature that are valid, reliable, reproducible, clinically relevant, provide for clinical flexibility, are subjected to multidisciplinary review, and are regularly updated to reflect current knowledge.

Practice Guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. These can simply be broad statements or be very detailed based on literature review as well as expert opinion. Typically, clinical guidelines reflect more than local consensus regarding appropriate diagnosis and treatment of a condition. Clinical guidelines also can be developed to describe the indications for procedures and the process of care.

The Agency for Healthcare Research and Quality -- AHRQ (formerly the Agency for Health Care Policy and Research -- AHCPR) uses the term "clinical practice guidelines" to describe systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical conditions. These are written by independent multidisciplinary panels of private-sector clinicians and other experts, supported by AHRQ. Our committee will refer to AHRQ-type practice guidelines as practice parameters.

Clinical Algorithms are clinical guidelines prepared in a flow chart format, typically describing the process and decisions involved in addressing a specific condition. Alternate diagnostic and treatment approaches are described based upon decision points regarding information or judgments made about the patient.

Clinical or Critical Pathways document essential steps in the diagnosis and treatment of a condition or procedure for individual patients. They document a standard pattern of care to be followed for each patient. Often specific information on timing of each intervention is specified, with provision for recording variances and their reasons so that analysis can be performed to modify the pattern of care in order to avoid variances in the future. These are predominantly management tools and are based on clinical information developed in other guidelines or parameters. They are specific to the institution using them.

Protocols describe the process of care for individual patients (through pre-printed orders) developed to reflect the most cost-effective care for patients with that condition. Commonly, they serve to expedite care for routine problems.

Utilization Review Criteria are designed for either a concurrent or retrospective reviewer to use to determine if the essential information was recorded to establish a diagnosis, to determine whether appropriate treatment was chosen and to assess whether treatment was provided in an appropriate manner. Commonly, they are used to identify unjustified care, such as excessive procedures or extended length of stay.

Standards are accepted principles for patient management. These are rigidly applied rules, with rare exceptions and known consequences. These are developed to increase the probability of producing appropriate medical care. Commonly, they are used to determine if relevant and useful procedures were followed.

Outcome measurements are designed to be measurable consequences of care. These outcome measurements reflect patient health status, functional status, quality of daily living, physiologic parameters, and levels of satisfaction and well-being. Outcomes are used to measure the degree of a person or person s response to specific interventions such as rehabilitative management and treatment. In some managed care systems, outcome measurements actually refer to measurement of physician performance; the committee does not recommend this usage.

Source: "The Physiatrist," December 1995/January 1996

If you have ideas for practice guidelines or would like to participate in guideline development, please contact Lisa Kaplan, at lkaplan@aapmr.org or telephone (312) 464-9700. Your input is greatly appreciated.