Impact of Changes in Clinical Practice Guidelines on Assessment of Quality of Care

Division of General Internal Medicine, University of California, San Francisco, CA 94143-0320, USA.
Medical care (Impact Factor: 3.23). 08/2010; 48(8):733-8. DOI: 10.1097/MLR.0b013e3181e35b3a
Source: PubMed


Measures for pay-for-performance and public reporting programs may be based on clinical practice guidelines. The impact of guideline changes over time-and whether evolving clinical evidence can render measures based on prior guidelines misleading-is not known.
To assess the impact of using different percutaneous coronary intervention (PCI) guidelines when evaluating whether PCI was indicated.
PCIs from the National Cardiovascular Data Registry's CathPCI registry performed in 2003-2004 were categorized into indication classes (Class I, IIa, IIb, III), using 2001 American College of Cardiology/American Heart Association guidelines for PCI, the guidelines available at the time of the procedures. The same procedures were recategorized using 2005 guidelines, which reflect the best evidence available to clinicians at the time of PCI. Procedures unable to be categorized were labeled as "Not Certain."
Patients undergoing PCI for stable or unstable angina in 394 hospitals.
Number of procedures changing classification categories using 2001 versus 2005 guidelines.
A total of 345,779 PCIs were evaluated. Applying 2001 guidelines, 47.9% had Class I indications; 33.3% Class IIa; 5.9% Class IIb; 3.7% Class III; and 9.2% Not Certain. Applying 2005 guidelines to the same procedures, 25.1% had Class I indications; 57.5% Class IIa; 5.5% Class IIb; 3.7% Class III; and 8.3% Not Certain; 41.1% of procedures changed the classification overall.
The changes in guidelines resulted in a marked shift in whether PCIs done in 2003-2004 were considered indicated. Guideline-based performance measures should be carefully evaluated before implementation to avoid incorrect assessments of quality of care.

Download full-text


Available from: Rita Redberg
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: We present a technique for self-localisation of a mobile robot in structured office environments using a monocular on-board camera only. Most state of the art approaches to map building and localisation in mobile robotics are probabilistic. The majority depends on accurate proximity sensors such as laser range finders or sonar sensors. As an alternative, we have developed a probabilistic sensor model for robot vision. By matching straight-line segments extracted from the camera image with a geometrical model of the environment, it computes a probability that a given image has been obtained at a certain place in the robot's operating environment. The use of straight-line segments as features provides both computational efficiency and robustness with respect to noise and inaccuracies of the map. We have compared the performance of the sensor model with a traditional one for a laser range finder in the common framework of Monte-Carlo localisation. Given the results on robustness and accuracy of position estimation, our localisation technique is applicable for mobile robots in structured indoor environments that do not have laser sensors. Moreover, the model is appropriate for sensor fusion and object recognition.
    Full-text · Conference Paper · Jul 2004
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: This article summarizes the current state of technology as it pertains to quality in the operating room, ties the current state back to its evolutionary pathway to understand how the current capabilities and their limitations came to pass, and elucidates how the overlay of information technology (IT) as a wrapper around current monitoring and device technology provides a significant advance in the ability of anesthesiologists to use technology to improve quality along many axes. The authors posit that IT will enable all the information about patients, perioperative systems, system capacity, and readiness to follow a development trajectory of increasing usefulness.
    Full-text · Article · Mar 2011 · Anesthesiology Clinics
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) study, which provided optimal medical therapy (OMT) to all patients and demonstrated no incremental advantage of percutaneous coronary intervention (PCI) on outcomes other than angina-related quality of life in stable coronary artery disease (CAD), suggests that a trial of OMT is warranted before PCI. It is unknown to what degree OMT is applied before PCI in routine practice or whether its use increased after the COURAGE trial. To examine the use of OMT in patients with stable angina undergoing PCI before and after the publication of the COURAGE trial. An observational study of patients with stable CAD undergoing PCI in the National Cardiovascular Data Registry between September 1, 2005, and June 30, 2009. Analysis compared use of OMT, both before PCI and at the time of discharge, before and after the publication of the COURAGE trial. Optimal medical therapy was defined as either being prescribed or having a documented contraindication to all medicines (antiplatelet agent, β-blocker, and statin). Rates of OMT before PCI and at discharge (following PCI) between the 2 study periods. Among all 467,211 patients (173,416 before [37.1%] and 293,795 after [62.9%] the COURAGE trial) meeting study criteria, OMT was used in 206,569 patients (44.2%; 95% confidence interval [CI], 44.1%-44.4%) before PCI and in 303,864 patients (65.0%; 95% CI, 64.9%-65.2%) at discharge following PCI (P < .001). Before PCI, OMT was applied in 75,381 patients (43.5%; 95% CI, 43.2%-43.7%) before the COURAGE trial and in 131,188 patients (44.7%; 95% CI, 44.5%-44.8%) after the COURAGE trial (P < .001). The use of OMT at discharge following PCI before and after the COURAGE trial was 63.5% (95% CI, 63.3%-63.7%) and 66.0% (95% CI, 65.8%-66.1%), respectively (P < .001). Among patients with stable CAD undergoing PCI, less than half were receiving OMT before PCI and approximately two-thirds were receiving OMT at discharge following PCI, with relatively little change in these practice patterns after publication of the COURAGE trial.
    Full-text · Article · May 2011 · JAMA The Journal of the American Medical Association
Show more