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Los Angeles Times
Feb 17, 2003
by Trudy Lieberman, Special to The Times
Kaiser Web Site will be just what the doctor ordered -- and why;
To settle a consumer rights group's lawsuit, Kaiser Permanente will make its guidelines available online.Suppose your doctor says you have high blood pressure. What do you do next? If you're lucky, your doctor will follow a well-established guideline for your treatment. He or she may first prescribe diuretics and a low-salt diet before trying more potent and costly medications.
Medical, or clinical, guidelines are a sort of recipe that tells physicians how to treat diseases, which therapies to use and when more intervention is necessary. They are developed by medical specialty societies, such as the American College of Cardiology, government agencies, insurance consultants and sometimes by health plans.
In California, the 6.2 million members of Kaiser Permanente, the state's largest health maintenance organization, will soon be able to see the guidelines that their doctors use. As part of a legal settlement, Kaiser has agreed to post information on its Web site, www.kp.org, about the guidelines it recommends for Kaiser doctors. Kaiser's decision is the result of a lawsuit filed by the Foundation for Taxpayer and Consumer Rights, a California-based advocacy group that has criticized HMOs for being secretive about how treatment decisions are made.
Jamie Court, the foundation's executive director, calls the legal settlement a "landmark" in efforts to encourage health plans to be more forthcoming about their practices. Now, he says, "you can know how your case will be handled at the HMO and know what to expect."
These guidelines, based on scientific evidence about which treatments work and which don't, are the best tools patients have for improving the quality of their medical care. When patients have access to information that used to be known only to doctors, it helps shift the balance in the doctor-patient relationship toward more equitable decision-making.
"It will give people a basis to ask questions," says Dr. Carolyn M. Clancy, director of the federal Agency for Healthcare Research and Quality, which has taken the lead in promoting guidelines. "The whole point of guidelines is to make sure that the evidence gets translated into practice."
Guidelines, of course, are written for doctors, but they have a practical use for patients, especially when scientific evidence is not clear. Patients facing risky surgery may want to know what their doctors know about the recommended course of treatment and how strong the evidence is for a particular test. For example, the U.S. Preventive Services Task Force says that although there is evidence that screening can detect early-stage prostate cancer, it is inconclusive that early detection improves medical outcomes. The task force says there is not enough evidence to show whether benefits of the tests outweigh the risks.
Guidelines have the greatest potential for the 100 million Americans who have chronic illnesses, including diabetes, depression, back pain and high blood pressure. If you are suffering from depression, it might help to know that your doctor is prescribing medications that have been proved effective and not simply those pushed by drug companies.
For sudden illness, however, guidelines may be less useful. Imagine someone with crushing chest pains searching the Internet for appropriate treatment for a heart attack.
Guidelines are a two-way street. If doctors are serious about improving patient care, they must use them. Physicians can also use guidelines as proof of what works when patients demand certain treatments, such as drugs they've seen advertised on television or antibiotics to treat a cold.
But according to a study published in late January in the Journal of the American Medical Assn., most doctors are not using guidelines. Researchers discovered that only 11% of physician organizations used clinical guidelines to treat patients with four chronic conditions -- diabetes, asthma, congestive heart failure and depression -- for which treatment protocols should be of help.
Instead of guidelines, doctors often make decisions based on what has worked in the past, what treatments are promoted by medical equipment and drug manufacturers or what they were taught in medical school. The notion of using scientific evidence to inform medical decisions is new, and some physicians have been slow to embrace it.
Guidelines are sometimes controversial. Some patient advocacy groups and doctors have argued that guidelines result in "cookbook" medicine that results in denying necessary care to patients. Self-interest, though, may also be at work.
Some doctors are not keen on following guidelines that omit a procedure that they do routinely -- and from which they earn a good deal of their income. Whether other HMOs will follow Kaiser's lead is unknown.
"Kaiser has devoted tremendous resources to figuring these things out," says Jeffrey C. Lerner, president of ECRI, a group that evaluates hospital equipment and, with the Agency for Healthcare Research and Quality, operates the National Guideline Clearing House, an Internet site that publishes treatment guidelines for many diseases. "There's no force to make guidelines translate to a non-Kaiser setting because there's no control over physicians."
Kaiser is a health care delivery system as well as an insurance payer. Other HMOs pay bills but have much less influence over the way their doctors practice medicine.
Trudy Lieberman can be reached by e-mail at firstname.lastname@example.org
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