Clinical Policies: Their History, Future, Medical Legal Implications, and Growing Importance to Physicians

Napoli, Anthony M.; Jagoda, Andy

doi:10.1016/j.jemermed.2007.02.050

Cited by 8 publications

(7 citation statements)

References 49 publications

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“…The rapid expansion of medical literature in recent decades has provided increased access to evidence that can improve health care delivery, yet much of this information has been published without curation, thereby limiting translation into practice (1)(2)(3)(4). To address this, clinical practice guidelines (CPGs) were developed to provide synthesized and critically appraised scientific evidence to enhance medical decision-making.…”

Section: Introductionmentioning

confidence: 99%

“…One of the many medical specialties promulgating CPGs is emergency medicine. Guidelines specifically for emergency care were first published by the American College of Emergency Physicians (ACEP) in 1990 to answer specific, clinically relevant questions considered to be of high frequency or high risk in emergency medicine (1,2). However, ACEP's 2013 clinical policy on intravenous tissue plasminogen activator (tPA) use in acute ischemic stroke sparked controversy with concerns for bias in development (12)(13)(14)(15), resulting in substantial reevaluation of the clinical policy development process, rating methodology, and management of conflicts of interest (15).…”

Section: Introductionmentioning

confidence: 99%

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An appraisal of emergency medicine clinical practice guidelines: Do we agree?

et al. 2018

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Background: Clinical practice guidelines (CPGs) have been published by the American College of Emergency Physicians (ACEP) since 1990 to advance evidence-based emergency care. ACEP clinical policies have drawn anecdotal criticism for bias, yet the overall quality of these guidelines has not previously been quantified. We sought to examine ACEP clinical policies using a recognized, validated appraisal instrument: Appraisal of Guideline for Research & Evaluation (AGREE II). Methods: Systematic assessment of current ACEP clinical policies using the AGREE II instrument, which contains 23 appraisal items (scored on a 1-7 scale) in six domains and two overall assessments. Each policy was independently appraised by five trained appraisers. Primary outcomes were AGREE II ratings for each item, domain, and "Overall Assessment," and scores were reported as standardized percentages from all five appraisers. Secondary analyses examined associations between AGREE II ratings and policy publication date, strength of underlying evidence, and strength of recommendations. Additional analysis examined relationships between domain and "Overall Assessment" ratings. Results: Twenty guidelines published from April 2007 to November 2017 were included. Of the six domains, "Scope and Purpose" scored highest (mean 90%) and "Applicability" scored lowest (mean 35%). The four remaining domains ("Stakeholder Involvement," "Rigor of Development,"

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

An appraisal of emergency medicine clinical practice guidelines: Do we agree?

et al. 2018

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“…To date, despite attempts to strengthen the ACEP Clinical Policy development process and growth in emergency care research funding and output, the strength of evidence that supports recommendations within emergency medicine promulgated clinical guidelines is not known. [10–13]…”

Section: Introductionmentioning

confidence: 99%

Systematic review of emergency medicine clinical practice guidelines: Implications for research and policy

et al. 2017

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IntroductionOver 25 years, emergency medicine in the United States has amassed a large evidence base that has been systematically assessed and interpreted through ACEP Clinical Policies. While not previously studied in emergency medicine, prior work has shown that nearly half of all recommendations in medical specialty practice guidelines may be based on limited or inconclusive evidence. We sought to describe the proportion of clinical practice guideline recommendations in Emergency Medicine that are based upon expert opinion and low level evidence.MethodsSystematic review of clinical practice guidelines (Clinical Policies) published by the American College of Emergency Physicians from January 1990 to January 2016. Standardized data were abstracted from each Clinical Policy including the number and level of recommendations as well as the reported class of evidence. Primary outcomes were the proportion of Level C equivalent recommendations and Class III equivalent evidence. The primary analysis was limited to current Clinical Policies, while secondary analysis included all Clinical Policies.ResultsA total of 54 Clinical Policies including 421 recommendations and 2801 cited references, with an average of 7.8 recommendations and 52 references per guideline were included. Of 19 current Clinical Policies, 13 of 141 (9.2%) recommendations were Level A, 57 (40.4%) Level B, and 71 (50.4%) Level C. Of 845 references in current Clinical Policies, 67 (7.9%) were Class I, 272 (32.3%) Class II, and 506 (59.9%) Class III equivalent. Among all Clinical Policies, 200 (47.5%) recommendations were Level C equivalent, and 1371 (48.9%) of references were Class III equivalent.ConclusionsEmergency medicine clinical practice guidelines are largely based on lower classes of evidence and a majority of recommendations are expert opinion based. Emergency medicine appears to suffer from an evidence gap that should be prioritized in the national research agenda and considered by policymakers prior to developing future quality standards.

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“…With increasing adoption of easily accessible and referenced guidelines, it should become possible to study guideline adherence regarding the transfer of patients. As has been the case with widely adopted intrahospital and national guidelines, 59 studies on adherence should inform quality analyses, patient and provider satisfaction surveys, and outcomes studies and should inform future guideline development.…”

Section: Web‐based Collaborative Technologiesmentioning

confidence: 99%

Electronic Collaboration: Using Technology to Solve Old Problems of Quality Care

Baumlin

Genes

Landman

et al. 2010

Academic Emergency Medicine

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The participants of the Electronic Collaboration working group of the 2010 Academic Emergency Medicine consensus conference developed recommendations and research questions for improving regional quality of care through the use of electronic collaboration. A writing group devised a working draft prior to the meeting and presented this to the breakout session at the consensus conference for input and approval. The recommendations include: 1) patient health information should be available electronically across the entire health care delivery system from the 9-1-1 call to the emergency department (ED) visit through hospitalization and outpatient care, 2) relevant patient health information should be shared electronically across the entire health care delivery system, 3) Web-based collaborative technologies should be employed to facilitate patient transfer and timely access to specialists, 4) personal health record adoption should be considered as a way to improve patient health, and 5) any comprehensive reform of regionalization in emergency care must include telemedicine. The workgroup emphasized the need for funding increases so that research in this new and exciting area can expand. ACADEMIC EMERGENCY MEDICINE 2010; 17:1312-1321 ª 2010 by the Society for Academic Emergency Medicine T he world of information technology is rapidly changing, yet changes in health care have been slow. 1-3 The science supporting how information technology will affect regionalization is sparse in many areas, although it is growing. The purpose of this article is to report on the efforts of the 2010 Academic Emergency Medicine consensus conference workgroup tasked with exploring the research agenda for how to improve regionalization through electronic collaboration. We decided to focus on the following broad topics: electronic health record (EHR) implementation, regional health information exchange (HIE), Web-based collaborative tools, personal health records, and tele-medicine. When considering EHRs, it is necessary to consider the nationwide status of emergency department (ED) EHR implementation. The 2003 survey by Pallin et al. 4 and the recent work of Landman et al. 5 suggest low levels of full implementation, although recent publications suggest both improved efficiencies and financial gain can be achieved with comprehensive implementation of fully integrated EHRs. 6,7 The question now is not if EDs will implement fully functioning EHRs, but when. The next wave of implementation work will involve ED EHR integration of prehospital data and should help answer whether capturing and sharing prehospital data improves the overall care of patients. While EDs implement EHRs, will currently available technology be employed in other realms to enhance regional networks of care? We already know that regional stroke centers, trauma centers, and heart centers can improve outcomes. 8-10 Perhaps simply sharing, comparing, and studying the protocols already in place that drive physician decision-making can affect care and quality across regions. T...

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Clinical Policies: Their History, Future, Medical Legal Implications, and Growing Importance to Physicians

Cited by 8 publications

References 49 publications

An appraisal of emergency medicine clinical practice guidelines: Do we agree?

An appraisal of emergency medicine clinical practice guidelines: Do we agree?

Systematic review of emergency medicine clinical practice guidelines: Implications for research and policy

Electronic Collaboration: Using Technology to Solve Old Problems of Quality Care

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