American College of Physicians: Internal Medicine — Doctors for Adults ®

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A look at the College's effort to examine 'best practices'

From the May 1999 ACP-ASIM Observer, copyright 1999 by the American College of Physicians-American Society of Internal Medicine.

By Phyllis Maguire

A new College research project is examining to what extent physicians follow "best practices." The project, known as the Quality Network or QNet, will assess data provided by a group of volunteer physicians about how they treat diabetes, congestive heart failure and asthma, how they screen for cholesterol and how they administer warfarin. The program, which grew out of the former ASIM Clinical Practice Guidelines Network, has about 145 physician volunteers. It is funded by an unrestricted educational grant from Hoechst Pharmaceuticals and overseen by the College's Scientific Policy Department, under Director Christel Mottur-Pilson, PhD. ACP-ASIM Observer recently talked to Dr. Mottur-Pilson about QNet.

Q: Why is it important to know how actual treatments deviate from what are considered "best practices"?

A: So often physicians are faulted for guideline deviations when they may actually have a very good reason. One distinctive feature of our research is that physicians can indicate in a sentence or two why they chose to deviate. It provides them with the opportunity to explain their reasons for not following a particular protocol.

The congestive heart failure guideline, for example, may recommend titrating one of the ace inhibitors up to the maximum dose, but the doctor may decide not to because the patient has kidney disease. Or perhaps the guidelines can't be followed because a patient is not compliant. By giving doctors the opportunity to explain what the reason is for not following a protocol, they can make their case.

Q: How is the project conducted?

A: We send physicians clinical guidance templates that they fill out at the point of care. Each template is no longer than two pages and most of the responses require a check mark. The templates were developed by a physician advisory group that worked with ASIM's Internal Medicine Center to Advance Research and Education (IMCARE).

Q: How does the data get back to the College, and how soon?

A: The physicians send back paper copies, and there really is no timeframe attached to the project. I assume that because most physicians don't see 40 diabetes individuals in one day, we have to allow several weeks or months until we receive data we can analyze and start giving feedback. I anticipate that this will be an ongoing activity for at least a year.

Q: What will you do with the results?

A: We might write an article for Annals of Internal Medicine or Best Evidence, or the project might lead to further research. One thing we do promise is that all participants will receive comments on their data in terms of how they compare with their peers.

So often, doctors are convinced that they're doing the right thing, but they don't have the luxury to consciously look at 25 or 30 charts to see whether they have actually done the right thing in each instance. When they have to document treatments and look at the totality of cases, they find that they might have slipped on three or four for some reason.

Q: Will the results affect the College's guideline procedures?

A: We may find that we need to modify our clinical guidance statements if doctors consistently deviate from recommendations for good reason. Additional research may be called for to elucidate the reasons for the difference between clinically controlled trials, also known as efficacy research, and effectiveness research, namely what happens in actual physicians' offices.

The project is really a reality check of treatment recommendations and why they are not met. The College is trying to bridge the gap between best practice and actual practice via a type of hands-on intervention.

Q: How can other physicians participate?

A: Physicians interested in becoming QNet participants should contact Joel A. Harrison, PhD, MPH, at jharrison@acponline.org or fax him at 215-351-2594.

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