Commentary (Wade): Current Status of Practice Guidelines in Oncology

This new topic, practice guidelines in oncology, has emerged for one primary reason-managed care. Now that insurance companies have developed the software to measure wide variations in practice behavior, they have quickly realized that appropriate care is less expensive than maximum care. The development of guidelines is a tool to identify what constitutes appropriate care, and what can be culled out as inappropriate care and therefore not reimbursed. To balance this initiative, oncology guidelines written by oncologists are appearing in order to identify what may be too little care.

The guideline on colony-stimulating factors (CSFs) developed by the American Society of Clinical Oncology [1] is a landmark in this process. During the 1-1/2 years that the CSF expert panel worked on the project, various third-party payors, including Medicare, arrived at a variety of guidelines that set parameters for reimbursement for CSF use that are far more stringent than the FDA label. The ASCO guidelines on CSFs, published in November 1994, established the national standard to protect patients from financially driven underuse, and also to help describe a ceiling to better identify overuse.

Subsequent guidelines for measurment of serum tumor markers and the use of peripheral stem-cell support will also be based on the available data and scientific literature, with thoughtful analysis by an expert panel. The publication of such guidelines in the medical literature, and the establishment of similar guidelines by state oncology societies, determine for medical, legal, and reimbursement purposes what treatment patients can receive or can expect. Both the national professional societies and the state oncology societies will continue to play a key role in the implementation of this dynamic process, which helps balance two opposing sets of forces, ie, too much care and too little care.

Far More Difficult Issue

This is the first phase of a long process. The next, and far more difficult issue, is how to implement and measure guidelines. The tracking of physician coding behavior, and the subsequent translation of that information into clinical practice, is extremely difficult. Some insurance companies that became involved in the follow-up guidelines issue over the last 2 years have now realized that trying to relate what the billing codes demonstrate to what the guidelines suggest is a near impossible task.

Many experts have reviewed past guideline initiatives and have found that physician compliance with guidelines, once established, is extremely low [2]. As yet, no one really knows how to monitor the implementation of treatment guidelines, let alone what type of mechanism should be established to alter physician behavior so that it is in better compliance with such guidelines. It is imperative that both state oncology societies and the national professional organizations work closely together, so that when such a system is finally created, it carries the traditional best interests of patients as the most important criteria for treatment decisions. The mechanism and control of physician practice behavior will ultimately be financed by the payors of health care. It is up to the providers (us) to insure that oncology care remains a profession, not just a business.

References:

1. American Society of Clinical Oncology: American Society of Clinical Oncology recommendations for the use of hematopoietic colony stimulating factors evidence based clinical practice guidelines. J Clin Oncol 12(11):2471-2508, 1994.

2. Lomoss J, Anderson GR, Dominick-Pierre K, et al: Do practice guidelines guide clinical practice? The effect of a consensus statement on the practice of physicians. N Engl J Med 321(19):1306-1311, 1989.