Is health plan employer data and information set performance associated with withdrawal from medicare managed care?

Clinical Practice Guidelines and Performance Indicators as Related—But Often Misunderstood—Tools

BACKGROUND

Widespread variation in medical practice indicates that existing scientific evidence is often not translated into appropriate clinical care. Two tools have evolved that try to address this variation: clinical practice guidelines (CPGs) and performance indicators (PIs).

TENSIONS BETWEEN CPGS AND PIS

CPGs present available evidence that is subsequently reviewed and frequently adopted by professional organizations, so that clinicians may judge whether specific management recommendations are appropriate for each patient. PIs are devised to measure and document performance to motivate organizations to improve through the use of common metrics.

IMPLICATIONS OF THESE TENSIONS

The increasingly widespread use of PIs with CPGs (and clinicians' confusion of them with CPGs) risks lowering the standards of clinical care. PIs are not intended to set optimal standards of care for any individual patient. Clinicians should not restrict their quality monitoring to a focus on PIs because they could miss important opportunities to learn and to improve the care they deliver to their individual patients.

CONCLUSION

Tensions between CPGs and PIs do not mean that these tools should be abandoned but rather that they need to be refined. Recognition of the imperfections of CPGs and PIs should not blind clinicians to the ultimate goals of these tools--to promote quality (through changes in practice and/or selection) and ensure that medical care is based on scientific evidence.