Are preferred practice patterns having the desired impact?

June 15, 2005

About 20 years ago, a number of organizations came up with an idea of written guidelines for disease management. The idea was met with skepticism in some circles.

About 20 years ago, a number of organizations came up with an idea of written guidelines for disease management. The idea was met with skepticism in some circles.

As a resident, I recall one faculty member deriding these as trying to reduce clinical practice to "cookbook medicine." The idea that all patients could be treated in the same manner made little sense to this professor. The dean at the time was concerned that the guidelines would stifle medical innovation. I remember his comments that if such written guidelines had been started a century ago, "we would still be bleeding people with leeches." Some objected that doctors would be forced to follow these guidelines slavishly. If the guidelines were outdated, did not apply to an individual patient, or were just plain wrong, physicians would still be reluctant to deviate from them for fear of exposing themselves to malpractice lawsuits.

These written guidelines, referred to as preferred practice patterns, are now abundant. Panels of experienced clinicians and academicians have produced documents with consensus recommendations for diagnostic testing and therapy. As a service to its membership, the American Academy of Ophthalmology has published a large number of these documents, covering various topics including management of cataracts, refractive error, glaucoma, diabetic retinopathy, and corneal ulcers. In addition, literature reviews have resulted in numerous "evidence-based medicine" recommendations regarding the "science" behind "proven" management strategies.

Several years ago, I authored or co-authored a few papers1-3 describing how the management of bacterial corneal ulcers by busy clinicians differed from published recommendations. Contrary to the published "practice pattern," most clinicians did not routinely scrape and culture ulcers, and commercially available antibiotics were overwhelmingly preferred to specially prepared fortified antibiotics. Why? I asserted that this discrepancy related to a number of factors: Gram stain and culture results rarely guided therapy, and commercially available fluoroquinolone antibiotics were less expensive but as effective as the recommended fortified two-agent therapy.

But this discrepancy was not an isolated instance.

Why? The rationale I proposed with keratitis does not seem to apply. Eye exams in patients with diabetes certainly do guide therapy, and laser photocoagulation is proven to be cost-effective. Similarly, gonioscopy guides therapy (open-angle glaucoma is usually managed differently from narrow-angle glaucoma), and nerve head changes are important signs of disease progression and hence guides to therapy.

Is the issue one of a need to educate clinicians better about the treatment guidelines? Are 20-page written guidelines poor vehicles for conveying these recommendations? Are many of us too busy to learn about and incorporate these "evidence-based" pearls into our practices? Are the recommendations of expert subspecialists in some ways impractical, so that busy comprehensive ophthalmologists cannot or will not implement them?

It seems to me that the consensus documents published by panels of experienced clinicians that have been considered the final work product may instead simply be starting points. The hard work may be figuring out how to make sure the important information within these documents gets incorporated into clinical practice.

References 1. McDonnell PJ, Nobe J, Gauderman WJ, Lee P, Aiello A, Trousdale M. Community care of corneal ulcers. Am J Ophthalmol 1992;114:531-538.

2. McLeod SD, Kolahdouz-Isfahani A, Rostamian K, Flowers CW, Lee PP, McDonnell PJ. The role of smears, cultures, and antibiotic sensitivity testing in the management of suspected infectious keratitis. Ophthalmology 1996;103:23-28.

3. McDonnell PJ. Empirical or culture-guided therapy for microbial keratitis? A plea for data. Arch Ophthalmol 1996;114:84-87.