Barbara O. Wynn

Rigorous Development does not Ensure that Guidelines are Acceptable to a Panel of Knowledgeable Providers

BACKGROUNDRigorous guideline development methods are designed to produce recommendations that are relevant to common clinical situations and consistent with evidence and expert understanding, thereby promoting guidelines’ acceptability to providers. No studies have examined whether this technical quality consistently leads to acceptability.OBJECTIVETo examine the clinical acceptability of guidelines having excellent technical quality.DESIGN AND MEASUREMENTSWe selected guidelines covering several musculoskeletal disorders and meeting 5 basic technical quality criteria, then used the widely accepted AGREE Instrument to evaluate technical quality. Adapting an established modified Delphi method, we assembled a multidisciplinary panel of providers recommended by their specialty societies as leaders in the field. Panelists rated acceptability, including “perceived comprehensiveness” (perceived relevance to common clinical situations) and “perceived validity” (consistency with their understanding of existing evidence and opinions), for ten common condition/therapy pairs pertaining to Surgery, physical therapy, and chiropractic manipulation for lumbar spine, shoulder, and carpal tunnel disorders.RESULTSFive guidelines met selection criteria. Their AGREE scores were generally high indicating excellent technical quality. However, panelists found 4 guidelines to be only moderately comprehensive and valid, and a fifth guideline to be invalid overall. Of the topics covered by each guideline, panelists rated 50% to 69% as “comprehensive” and 6% to 50% as “valid”.CONCLUSIONDespite very rigorous development methods compared with guidelines assessed in prior studies, experts felt that these guidelines omitted common clinical situations and contained much content of uncertain validity. Guideline acceptability should be independently and formally evaluated before dissemination.

A Comparison of Ambulatory Perioperative Times in Hospitals and Freestanding Centers

BACKGROUND The volume of surgical procedures performed in ambulatory surgical centers has increased rapidly. METHODS Ambulatory surgical visits of Medicare beneficiaries were compared for hospital-based and freestanding ambulatory surgical centers (ASCs). The main outcomes were time in surgery, time in operating room, time in postoperative care, and total perioperative time. RESULTS The mean total perioperative time for all procedures examined was 39% shorter in freestanding ASCs then in hospital-based ASCs (83 vs 135 min; P < .01); surgery time was 37% shorter (19 vs 30 min; P < .01), operating room time was 37% shorter (34 vs 54 min; P < .01), and postoperative time was 35% shorter (48 vs 74 min; P < .01). CONCLUSIONS Perioperative times were significantly shorter in freestanding ASCs than in hospital-based ASCs. It is unclear how much of the difference was the result of efficiency versus patient selection.

Medicare's Step Back from Global Payments — Unbundling Postoperative Care

Owing to concerns about the accuracy of payments for postoperative care, the Centers for Medicare and Medicaid Services has announced that surgeries for which it has bundled payments for care during a 10- or 90-day global period will be shifted to a 0-day global period.

Selection of workers' compensation treatment guidelines: California experience.

Objective: Workers’ compensation systems increasingly use mandatory treatment guidelines to guide clinicians and for utilization management. This article describes the steps for selecting such guidelines. Methods: On the basis of experience with the RAND/University of California, Los Angeles project to help California select guidelines, we identified the necessary choices and processes for guideline selection and evaluation. Results: Major steps in guideline selection include: 1) define purpose; 2) assign decision-making authority; 3) decide whether to use existing guidelines or develop new ones; 4) choose whether to use one or multiple existing guidelines; 5) specify clinical topics that guidelines should address; 6) identify and screen guidelines; 7) evaluate guidelines; 8) consider implications of results; 9) select guideline(s); 10) disseminate selection; and 11) assess long-term effectiveness. Conclusions: Given the many choices required, selecting mandatory workers’ compensation guidelines should involve careful planning and a transparent, well-defined process.

Developing Codes to Capture Post-Operative Care

This report makes recommendations to the Centers for Medicare & Medicaid Services on a set of nonpayment codes that can be used to collect information on the number and level of post-operative visits. The proposed nonpayment codes aim to capture the major differences in the breadth and intensity of post-operative care provided to Medicare beneficiaries.