Monday, 7 November 2016

Basic instruments for clinical management

In preparing this post I have chosen nine references which, in my opinion, have been milestones in the development of methodologies and tools that have shaped clinical management as we understand it today. To make it more understandable, I have framed these milestones in 5 relevant periods: the introduction of the concepts of quality in the 60s, the protocols in the 70s, the consensus in the 80s, the evidence of 90s and the safety of patients in the first decade of this century.


Avedis Donabedian published "Evaluating the Quality of Medical Care" in 1966*, a document that laid the groundwork for the introduction of assessment methodology in medical practice, until then a quiet and dark matter. The three concepts proposed by Donabedian: a) accreditation of structures, b) assessment of process indicators, and c) evaluation of performance indicators. These have been extremely useful for the modernization of health services. Years later, the same author published in Science "The quality of medical care", an article that spread interest in quality measurement in the entire universe of clinical practice, beyond the strict field of public health and health administration.
* The link leads to a re-edition from 2005, because the original is not available.


In 1973, the US Institute of Medicine published the book "A Strategy for Evaluating Health Services", a work that defined a model to generate tracers of the most common clinical performances. With this initiative, IOM promoted the definition of protocols in order to achieve standardized clinical work. Despite the obvious limitations, tracers’ dynamics and protocols introduced a dose of rigor in medical practice, in addition the possibility to audit the clinical processes.


In 1984, a group of Californian researchers published "Consensus Methods: Characteristics and Guidelines for Use" giving the starting signal for the application of methods of consensus in the health sector. With this push, the National Institute of Health (NIH) launched a consensus program to generate professional debate structured on controversial and innovative themes, and so it happened that at the time of establishing criteria and recommendations for the management of certain clinical situations, the Delphi method, the nominal groups and the consensus conferences became popular. Finally, another document, "Changing Medical Practice through Technology Assessment" in 1989, assessed that the impact of the NIH Consensus program was lower than expected so the funds allocated dwindled.


In 1992 a team of epidemiologists at McMaster University, led by Gordon Guyatt, published "Evidence-Based Medicine. A New Approach to Teaching the Practice of Medicine", a methodology that aims to facilitate the arrival of scientific findings to the world of clinical practice; and in 1995, David Sackett, from the same McMaster group, published the book "Evidence-Based Medicine" which led to the development of evidence scales and promoted the development of clinical practice guidelines. The result of this dynamic, in 1993 Cochrane Collaboration was founded, a collaborative organization that collects, analyzes and disseminates the best available evidence in order to enhance clinical practice.


In November 1999, the US Institute of Medicine published "To Err is Human," a damning report on the undesirable effects and complications caused by medical action and by the health system in general. Although the figures were tied to the American context, the document forced all governments around the world to deploy patient safety programs with the intention to make health institutions safer places for patients. As part of this movement, some very effective programs were deployed such as promoting hand washing, patient identification, records of incidents or the surgical checklist, described by the surgeon Atul Gawande in the book "The Checklist Manifesto". 

And the second decade of this century, how will it be remembered as? (in the field of clinical management, of course). Well, undoubtedly, our milestone should be the enhancement of value clinical practice in detriment of the overdiagnosis and overtreatment. This is our challenge.

Jordi Varela

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