The Opportunity Cost of Clinical Guidelines
The benefits of guidelines are undisputed, and there is no question that they should be an essential element of health care planning. However, in the United States guidelines are usually developed without considering that a key limiting resource in health care provision is provider time and that an assessment of the comparative effectiveness of the alternative scenarios under consideration is needed.
That provider time is limited means that some guidelines are essentially unfunded (in terms of time) mandates, asking the provider to do more without giving additional time to do it. This unfunded mandate means (1) providers ration care provided to the same patient or other patients later in the day; (2) this rationing may be suboptimal since the effectiveness of the new guideline ignores the effect of what care will be dropped; (3) since providers do not record what was dropped to make room for the new service, one can never know the opportunity cost in terms of health, costs, or cost-effectiveness of an intervention; and (4) the effect of performance measures, which are based on guidelines, also is unknown.
The solutions are not obvious. One approach is to evaluate guidelines from a broader perspective. However, this is impractical because there are so many potential scenarios and the methods to perform this evaluation do not exist. Clearly, more research on how busy clinicians prioritize and make choices about the implementation of clinical guidelines with limited information, and how this information processing can be improved, is needed. While electronic medical records and computer system prompts have been developed to alert providers to the guidelines indicated for each patient, these methods do not prioritize interventions to maximize effectiveness for each patient or across a population. This is not a computer systems problem; it is a lack of data on the relative effectiveness of individual guidelines. Similarly, the National Guidelines Clearinghouse website includes a "compare guidelines" functionality. However, it is only possible to compare guidelines within the same subtopic, and the tool does not include a comparison of effectiveness. Data might be available from practice-based research networks, but to date such data (and such functionality of the networks) are still lacking.
Clearly, a more realistic evaluation of the total effect of guidelines on individuals and across populations will require the development of new methods. Until this is done, the true impact of clinical guidelines cannot be known.
Where Now?
The benefits of guidelines are undisputed, and there is no question that they should be an essential element of health care planning. However, in the United States guidelines are usually developed without considering that a key limiting resource in health care provision is provider time and that an assessment of the comparative effectiveness of the alternative scenarios under consideration is needed.
That provider time is limited means that some guidelines are essentially unfunded (in terms of time) mandates, asking the provider to do more without giving additional time to do it. This unfunded mandate means (1) providers ration care provided to the same patient or other patients later in the day; (2) this rationing may be suboptimal since the effectiveness of the new guideline ignores the effect of what care will be dropped; (3) since providers do not record what was dropped to make room for the new service, one can never know the opportunity cost in terms of health, costs, or cost-effectiveness of an intervention; and (4) the effect of performance measures, which are based on guidelines, also is unknown.
The solutions are not obvious. One approach is to evaluate guidelines from a broader perspective. However, this is impractical because there are so many potential scenarios and the methods to perform this evaluation do not exist. Clearly, more research on how busy clinicians prioritize and make choices about the implementation of clinical guidelines with limited information, and how this information processing can be improved, is needed. While electronic medical records and computer system prompts have been developed to alert providers to the guidelines indicated for each patient, these methods do not prioritize interventions to maximize effectiveness for each patient or across a population. This is not a computer systems problem; it is a lack of data on the relative effectiveness of individual guidelines. Similarly, the National Guidelines Clearinghouse website includes a "compare guidelines" functionality. However, it is only possible to compare guidelines within the same subtopic, and the tool does not include a comparison of effectiveness. Data might be available from practice-based research networks, but to date such data (and such functionality of the networks) are still lacking.
Clearly, a more realistic evaluation of the total effect of guidelines on individuals and across populations will require the development of new methods. Until this is done, the true impact of clinical guidelines cannot be known.