Practice guidelines: role of economics and physicians

Impact of cost containment measures on medical liability

RATIONALE

Owing to the growing health care expenditure and the need to improve efficiency, public authorities have since the 1980s changed their policy with respect to health care. Financial pressures encouraged them to investigate methods to control health care costs. One recent method is the enactment of cost containment measures based on clinical practice guidelines (CPGs) that provide financial or administrative sanctions.

AIMS AND OBJECTIVES

This article describes the legal value of CPGs, the evolution towards cost containment measures based on CPGs, and finally the legal value of these new cost containment measures. It questions whether these measures may have an impact on the medical liability rules and it wants to open the debate on the legal value of these measures based vis-à-vis the professional autonomy of the physician and patients' rights on quality care.

METHODS

The research for this article is based on a comparative analysis of the legal literature and jurisprudence of a number of legal systems.

RESULTS AND CONCLUSIONS

The article concludes that, as a result of the rising costs, it becomes increasingly difficult for a physician to balance his duty to take care on the one hand and his duty to control costs on the other. Maintaining a high standard of care towards patients becomes difficult. Consequently, one wonders whether the law should then allow the standard of care to be adjusted according to the available means. Until now, courts in a fault based system have not been willing to accept such an adjustment of the standard of care, but it might well be possible that this attitude will change in case of no-fault compensation systems.

Disease management: state of the art and future directions

Disease management (DM) programs have become common in health systems, especially in managed care organizations and hospitals. These programs are designed to improve both the quality of care and the efficiency of health care delivery. However, there may be controversy about the most important outcomes to consider. Furthermore, the effectiveness of DM initiatives is largely undocumented in the literature. The purpose of this paper is to review the issues, methods, and outcomes involved in creating and instituting DM programs. To improve DM efforts within health systems, constructive relationships with practitioners need to be built by involving important individuals early in the process. It is hoped that evidence-based guidelines will further enhance DM efforts. Beneficial DM initiatives require a multidisciplinary focus of cooperation and willingness to share data between distinct professional groups. More thorough analysis of DM programs is needed in many health systems.

The impact of clinical guidelines on practice patterns: doing more versus doing less

This study examined the determinants of compliance with clinical guidelines for glucocyte colony-stimulating factor (GCSF), a biotechnology product designed to reduce postchemotherapy infections. The pattern of compliance did change over time. After the guidelines were disseminated, appropriate use of GCSF increased. However, inappropriate use also increased. Patients who were younger and had an attending physician who was an oncologist or hematologist were more likely to receive GCSF whether they met the guideline criteria or not. Our findings suggest that older patients may be treated less aggressively than others and that physicians who are the most knowledgeable about guidelines may feel the most qualified to override the guidelines when they believe they do not apply. Our findings also demonstrate that it is easier to encourage physicians to do more for patients rather than less.