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Making Clinical Policy Explicit: Legislative Policy Making and Lessons for Developing Practice Guidelines

Published online by Cambridge University Press:  10 March 2009

Jonathan Lomas
Jonathan Lomas
Affiliation:
McMaster University
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Abstract

Promulgation of practice guidelines in medicine has increased interest in the structure of clinical policy making. It is argued that with a generic efinition of policy as “the rules governing the behavior of individuals or institutions,” clinical policy making is analogous to legislative policy making. Practice guidelines emphasize the advantages of making clinical policy more explicit. The structure of legislative policy making as evolved over many years to meet the challenge of making both the policies and the process of policy making explicit. Processes to promulgate clinical policies may be able to exploit this experience to improve clinical policy making and thereby retain control of the process within medicine. Generic steps are outlined for making decisions with incomplete information; synthesis of facts, vested interests, and values; involvement of stakeholders; and implementation of policy. An illustration of the use of the generic steps to make and implement a clinical policy for cesarean birth follows, with evaluations of its impact on the behavior and satisfaction of clinical stakeholders.

Type
General Essays
Information
International Journal of Technology Assessment in Health Care , Volume 9 , Issue 1 , Winter 1993 , pp. 11 - 25
Copyright
Copyright © Cambridge University Press 1993

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References

REFERENCES

1.Allison, G. T.Implementation analysis: The “missing chapter” in conventional analysis illustrated by a teaching exercise. In Lewin, L. & Vedung, E. (eds.), Politics as rational action: Essays in public choice and policy analysis. Boston: Reidel Publishing, 1980, 237–60.CrossRefGoogle Scholar
2.American Medical Association. Directory of practice parameters. Chicago, IL: American Medical Association, 1990.Google Scholar
3.Anderson, G. M., & Lomas, J.Determinants of the increasing cesarean birth rate: Ontario data 1979 to 1982. New England Journal of Medicine, 1984, 311, 887–92.CrossRefGoogle ScholarPubMed
4.Anderson, G. M., & Lomas, J.Recent trends in cesarean section rates in Ontario. Canadian Medical Association Journal, 1989, 141, 1049–53.Google ScholarPubMed
5.Avorn, J., & Soumerai, S.Improved drug therapy through educational outreach: A randomized controlled trial of academically based detailing. New England Journal of Medicine, 1983, 308, 1457–63.CrossRefGoogle ScholarPubMed
6.Avorn, J., Chen, M., & Hartley, R.Scientific vs. commercial sources of influence on the prescribing behavior of physicians. American Journal of Medicine, 1982, 73, 4–8.CrossRefGoogle Scholar
7.Bardach, E.The implementation game: What happens after a bill becomes a law. Cambridge, MA: MIT Press, 1977.Google Scholar
8.Barnsley, J. M., Vayda, E., Lomas, J., et al. Cesarean section in Ontario: Practice patterns and responses to hypothetical cases. Canadian Journal of Surgery, 1990, 33, 128–32.Google ScholarPubMed
9.Boulding, K. E.The boundaries of social policy. Social Work, 1967, 12, 3–11.Google Scholar
10.Cragin, E. B.Conservatism in obstetrics. New York State Journal of Medicine, 1916,104,1–3.Google Scholar
11.Doern, G. B., & Phidd, R. W.Canadian public policy. Ideas, structure, process. Toronto: Methuen, 1983.Google Scholar
12.Dror, Y.Public policy making reexamined. San Francisco, CA: Chandler, 1968.Google Scholar
13.Eddy, D. M.Clinical policies and quality of clinical practice. New England Journal of Medicine, 1982, 307, 343–47.CrossRefGoogle ScholarPubMed
14.Eddy, D. M.Guidelines for policy statements: The explicit approach. Journal of the American Medical Association, 1990, 263, 2239–43.CrossRefGoogle ScholarPubMed
15.Eisenberg, J. M.Doctors’ decisions and the cost of medical care: The reasons for doctors’ practice patterns and ways to change them. Ann Arbor, MI: Health Administration Press, 1986.Google Scholar
16.Etzioni, A.The active society: A theory of society and political processes. New York: Free Press, 1968.Google Scholar
17.Field, M. J., & Lohr, K. N. (eds.). Clinical practice guidelines: Directions for a new program. Washington, DC: National Academy Press, 1990.CrossRefGoogle Scholar
18.Goodman, C. (ed.). Medical technology assessment directory: A pilot reference to organizations, assessments, and information sources. Washington, DC: National Academy Press, 1988.Google Scholar
19.Greer, A. L.The state of the art vs. the state of the science: The diffusion of new medical technologies into practice. International Journal of Technology Assessment in Health Care, 1988, 4, 5–26.CrossRefGoogle Scholar
20.Hammons, T.The use and contribution of practice guidelines. Background paper prepared for the conference to develop the research agenda for outcomes and effectiveness research, Washington, DC, 04, 1991.Google Scholar
21.Hampton, J. R.The end of clinical freedom. British Medical Journal, 1983, 287, 1237–39.CrossRefGoogle ScholarPubMed
22.Haynes, R. B., Davis, D. A., McKibbon, K. A., & Tugwell, P.A critical appraisal of the efficacy of continuing medical education. Journal of the American Medical Association, 1984, 251, 61–64.CrossRefGoogle ScholarPubMed
23.Jacoby, I.The consensus development program of the National Institutes of Health. International Journal of Technology Assessment in Health Care, 1985, 1, 420–32.CrossRefGoogle ScholarPubMed
24.Kanouse, D. E. (ed.). Changing medical practice through technology assessment. An evaluation of the N.I.H. consensus development program. Ann Arbor, MI: Health Administration Press, 1989.Google Scholar
25.Leape, L. L.Unnecessary surgery. Health Services Research, 1989, 24, 351–407.Google ScholarPubMed
26.Lind, E. A., & Tyler, T. R.The social psychology of procedural justice. New York: Plenum Press, 1988.CrossRefGoogle Scholar
27.Lindblom, C. E. The science of “muddling through.” Public Administration Review, 1959, 19, 79–99.CrossRefGoogle Scholar
28.Linder, S. H., & Peters, B. G.Policy formulation and the challenge of conscious design. Evaluation and Program Planning, 1990, 13, 303–11.CrossRefGoogle Scholar
29.Lomas, J.The consensus process and evidence dissemination. Canadian Medical Association Journal, 1986, 134, 1340–41.Google ScholarPubMed
30.Lomas, J.Holding back the tide of cesareans: Publishing recommendations is not enough to stop the rise. British Medical Journal, 1988, 297, 569–70.CrossRefGoogle Scholar
31.Lomas, J.Words without action? The production, dissemination and impact of consensus recommendations. Annual Review of Public Health, 1991, 12, 41–65.CrossRefGoogle ScholarPubMed
32.Lomas, J., & Anderson, G. M.Explaining variations in cesarean section rates: Patients, facilities, or policies? Canadian Medical Association Journal, 1985, 132, 253–59.Google Scholar
33.Lomas, J., Anderson, G. M., Domnick-Pierre, K., et al. Do practice guidelines guide practice? The effect of a consensus statement on the practice of physicians. New England Journal of Medicine, 1989, 321, 1306–11.CrossRefGoogle ScholarPubMed
34.Lomas, J., Anderson, G. M., Enkin, M., et al. The role of evidence in the consensus process: Results from a Canadian consensus exercise. Journal of the American Medical Association, 1988, 259, 3001–05.CrossRefGoogle ScholarPubMed
35.Lomas, J., Enkin, M., Anderson, G. M., et al. Opinion leaders vs. audit and feedback to implement practice guidelines. Delivery after previous cesarean section. Journal of the American Medical Association, 1991, 265, 2202–07.CrossRefGoogle ScholarPubMed
36.Lomas, J., & Haynes, R. B.A taxonomy and critical review of tested strategies for the appli cation of clinical practice recommendations: From ‘official’ to ‘individual’ clinical policy. American Journal of Preventive Me Heine, 1988, 4(suppl.), 77–94.Google Scholar
37.Majchrzak, A.Methods for policy research. London: Sage Publications, 1984.CrossRefGoogle Scholar
38.May, J. B., & Wildavsky, A. B. (eds.). The policy cycle. Beverly Hills, CA: Sage, 1978.Google Scholar
39.Morone, J. A.The democratic wish. Popular participation and the limits of American government. New York: Basic Books, 1990.Google Scholar
40.Munnell, A. H. (ed.). Lessons from the income maintenance experiments. Proceedings of a conference held at Melvin Village, New Hampshire, September 1986. Boston, MA: Federal Reserve Bank and the Brookings Institution, 1987.Google Scholar
41.Naylor, C. D., Basinski, A., Frank, J. W., & Rachlis, M. M.Asymptomatic hypercholesterolemia: A clinical policy review. Journal of Clinical Epidemiology, 1990, 43,1021–22.Google Scholar
42.Notzon, F. C., Placek, P. J., & Taffel, S. M.Comparisons of national cesarean-section rates. New England Journal of Medicine, 1987, 316, 386–89.CrossRefGoogle ScholarPubMed
43.Ontario. Appropriate use of cesarean section: Recommendations for a quality assurance program. Toronto: Ontario Ministry of Health, 1991.Google Scholar
44.Panel of the National Consensus Conference on Aspects of Cesarean Birth. Indications for cesarean section: Final statement of the panel of the National Consensus Conference on Aspects of Cesarean Birth. Canadian Medical Association Journal, 1986,134,1284–1352.Google Scholar
45.Phelan, J. P., & Clark, S. L. (eds.). Cesarean delivery. New York: Elsevier, 1988.Google Scholar
46.Pierre, K. D., Vayda, E., Lomas, J., et al. Obstetrical attitudes and practices before and after the Canadian consensus conference statement on cesarean birth. Social Science and Medicine, 1991, 32, 1283–89.CrossRefGoogle ScholarPubMed
47.Sabatier, P. A.An advocacy coalition framework of policy change and the role of policy-oriented learning therein. Policy Sciences, 1988, 21, 129–68.CrossRefGoogle Scholar
48.Sackett, D. L.Rules of evidence and clinical recommendations on the use of antithrombotic agents. Chest, 1986, 89(suppl.), 2S–3S.CrossRefGoogle ScholarPubMed
49.Schroeder, S. A.Strategies for reducing medical costs by changing physicians’ behavior: Efficacy and impact on quality of care. International Journal of Technology Assessment in Health Care, 1987, 3, 39–50.CrossRefGoogle ScholarPubMed
50.Soumerai, S. B., & Avorn, J.Principles of educational outreach ('academic detailing') to improve clinical decision making. Journal of the American Medical Association, 1990, 263, 549–56.CrossRefGoogle ScholarPubMed
51.Stone, D.Policy paradox and political reason. Boston, MA: Scott Foresman/Little Brown, 1988.Google Scholar
52.Stross, J. K., & Bole, G. G.Continuing education and rheumatoid arthritis for the primary care physician. Arthritis and Rheumatism, 1979, 22, 77–91.CrossRefGoogle Scholar
53.U.S. Department of Health and Human Services. AHCPR program note. Agency for Health Care Policy and Research. Washington, DC: The U.S. Government Printing Office, 0–861–842, 1990.Google Scholar
54.Wennberg, J. E.Dealing with medical practice variations: A proposal for action. Health Affairs, 1984, 3, 6–32.CrossRefGoogle ScholarPubMed
55.Wennberg, J. E.Outcomes research, cost containment, and the fear of health care rationing. New England Journal of Medicine, 1990, 323, 1202–04.CrossRefGoogle ScholarPubMed
56.Williamson, J. W., German, P. S., Weiss, R., et al. Health science information management and continuing education of physicians. Annals of Internal Medicine, 1989, 110, 151–60.CrossRefGoogle ScholarPubMed