June 1997
Volume 61 |
Number 6
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| ASA Practice Parameters:
An Update |
James F. Arens, M.D., Chair
Committee on Practice Parameters
ASA continues to be active in producing and promoting practice
guidelines. The ASA Board of Directors in March approved the development
of a new "Guideline for Peripheral Nerve Injury Reduction."
This topic has been selected since it remains the second greatest
problem in the number of claims made against anesthesiologists.
Claims involving adverse respiratory events continue to decline,
and there is a preliminary sense that the "Guidelines
for Management of the Difficult Airway" have been helpful
in defending anesthesiologists.
Guidelines Under Development or Review
The House of Delegates will be asked at the October 1997 meeting
to approve the "Guidelines on Preoperative Testing"
and the "Guidelines on Preoperative Fasting." Like practice
guidelines previously approved by our Society, these were to be
based primarily on scientific evidence obtained from literature
analysis. However, when the Task Force on Preoperative Testing
began to review the literature carefully, they discovered that
there was little evidence in the literature to support any recommendations.
Since it is felt to be important to have guidelines for preanesthetic
evaluation, the task force is developing a consensus-based document,
which will be presented to the October 1997 House of Delegates.
Similarly, a guideline on peripheral nerve injury reduction has
not been attempted previously because there is little scientific
evidence upon which to base an evidence-based guideline. Once
ASA decided to use consensus to develop a guideline, it was felt
that a "best practice" (consensus-based) guideline also
should be developed to help reduce the incidence of nerve injuries.
A guideline currently being developed on preoperative fasting
may be ready for consideration by the 1997 House of Delegates
in October. If the guideline is delayed because of the short-time
schedule, it will be ready for the 1998 House of Delegates.
Due to the complexities of obstetrical anesthesia, a guideline
on this subject is being developed and will be ready for presentation
to the 1998 House of Delegates. The Task Force on Obstetric Anesthesia
and the Task Force on Preoperative Fasting are cooperating to
prevent conflicting recommendations concerning NPO status for
patients undergoing anesthesia for an obstetrical procedure.
The "Practice
Guidelines for Management of the Difficult Airway," approved
in October 1992 and published in the March 1993 journal Anesthesiology,
has been recommended for review. Each guideline is to be reviewed
every five to seven years to determine if it should either be
discarded or updated. The review of the "Difficult Airway"
guidelines will focus on recent developments in clinical airway
management, particularly the impact of the laryngeal mask airway.
Activities of Methodology Unit
The extensive technical and analytic aspects of guideline development
for ASA have been successfully consolidated into a single, efficient
Methodology Unit. This unit is composed of two health service
analysts and one research librarian. The individuals utilize state-of-the-art
techniques for literature searching, clinical surveys and scientific
analysis of the available evidence. The activities of the Methodology
Unit are directly supervised by Robert A. Caplan, M.D., a member
of the Committee on Practice Parameters.
Sufficient experience has accumulated to describe the basic features
of a typical evidence-based guideline and the associated process
of development. Each guideline project is conducted by a task
force composed of eight to 10 ASA members. Each task force, in
turn, identifies 50 to100 consultants. Task force members and
consultants are chosen carefully to provide geographic diversity
and balance between academia and private practice. The progress
of each task force is monitored closely by an assigned member
of the Committee on Practice Parameters. Monitoring assures that
the guidelines are appropriate in scope and purpose.
Evidence for each guideline is obtained from scientific literature,
consultant opinion and practitioner experience. Literature searching
usually yields 2,000-3,000 citations for each guideline topic.
About 25 percent of citations contain data that can be used as
scientific evidence. Consultant opinion is obtained from five
to 10 formal surveys. Practitioner experience is derived from
feasibility studies and an open forum. In addition, commentary
and suggestions are solicited from the ASA Board of Directors
and the presidents of the ASA state component societies.
The final guideline product is usually eight to 10 typeset pages
in length and requires about 20 minutes for reading. Each guideline
recommendation is accompanied by a clear description of supporting
evidence. Whenever possible, guidelines provide "templates"
or "algorithms" that can facilitate the implementation
of key concepts or processes. The bibliographies provide a valuable
resource for local guideline implementation, continuing medical
education and scholarly inquiry.
Each guideline requires one to two years for completion. The
average expenditure for a typical guideline is approximately $150,000,
a cost that is considerably lower than that reported by other
medical specialties developing practice parameters. Meeting, transportation
and methodological support represent the three principal expenses.
The Methodology Unit makes extensive use of electronic data transmission
and is thereby able to operate as an "office without walls."
Physician participation is uncompensated. These last two factors
play an important role in minimizing the cost of guideline development.
The ASA Executive Office has made the text of each guideline
available on the Internet via the ASA Web site.
Who Develops Guidelines and Why?
Practice parameters are developed by a multitude of groups, e.g.,
national specialty societies, state societies, hospital medical
staffs, local physician networks, health maintenance organizations,
national hospital chains and third-party payers. The rationale
for developing such guidelines range from improving the quality
of medicine to putting money to the bottom line.
The medical profession, especially the American Medical Association
(AMA), continues to attempt to review these various guidelines
and to provide some "stamp of approval." The AMA through
the Practice Parameters Partnership and Forum has developed a
list of attributes that evaluate each guideline.
Although some progress has been made, the current mechanism is
not meeting our needs. As one actively participating in this process,
let me assure you that the effort will continue, but the difficulties
and issues are extremely complex. Let me also assure you that
the ASA practice guidelines are of the highest caliber and serve
as a model for the medical profession as a whole. Surprisingly,
the issues are methodological and not political.
Opponents of the practice guideline movement frequently say that
guidelines make malpractice easier to prove. While failure to
have a functioning oxygen analyzer and pulse oximeter will certainly
be difficult to defend in an anesthesia catastrophe, the parameter
recommending these devices is certainly pertinent and "on
target." On the contrary, the guidelines are frequently used
to assist the defense in achieving a suitable outcome for the
anesthesiologist being sued.
Practice parameters also have assisted physicians in reducing
medical costs. Guidelines can be developed by reviewing "best
practice" data and/or benchmarking. Significant cost-savings
have been achieved in renal transplantation and in surgery for
coronary artery disease using "best practice" data.
Cost-efficient medicine is not synonymous with rationing. Abuses
and/or poor judgment will occur with each and every movement.
Practice parameters, appropriately developed and applied, can
continue to exert a positive influence upon anesthesiology and
medicine. If they are developed from incorrect motives and inappropriately
applied, however, parameters will no doubt cause harm. Anesthesiology
through the ASA House of Delegates controls the process -- the
process is in good hands.
James F. Arens, M.D., is Vice President
for Clinical Affairs, Chief Executive Officer and Professor of
Anesthesiology at the University of Texas Medical Branch, Galveston,
Texas. He served as ASA President in 1989.
E-mail the author.
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