Cath Lab Digest

Laws and institutions must go hand in hand with the progress of the human mind. As that becomes more developed, more enlightened, as new discoveries are made, new truths discovered and manners and opinions change, with the change of circumstances, institutions must advance also to keep pace with the times.
- Thomas Jefferson, 1816

Hopeully, the January energy that seems to bring us a renewed resolve to get organized, to start over - to do things right - has not lost its momentum. This third year of this millennium we still face many of the same old problems that were present in healthcare last year, the year before that, and even 20 years ago.

Despite enormous accomplishments in medicine and exponential advances in technology, the quality of the healthcare provided in our country remains a problem. Americans spend $4,270 a year per person on healthcare,¹ more than any other country in the world. Recent government reports² and other publications³ underscore the need to examine the quality of our healthcare and the structure of its delivery system. One researcher³ believes our system has two underlying problems: 1) professional uncertainty with regard to clinical decision making, as well as with the establishment of guidelines or other criteria used to determine the appropriateness of care; and 2) rising costs and efforts to contain costs. An enormous chasm exists between the health services that should be provided (based on current professional knowledge and technology) and those that many patients actually receive. This all boils down to understanding the reasons for today's overuse, misuse, and underuse of medical technology.

Practice variances continue to be abundant. Great uncertainty exists among practitioners and among geographic locations and clinical settings ? particularly in the areas of wound, ostomy, and continence care. The lack of data persists despite the efforts and financial investments of professional organizations, manufacturers, the National Institutes of Health, and the Agency for Healthcare Research and Quality (AHCRQ, formerly the AHCPR). Each year, the AHCRQ spends more than $6 million to maintain a registry of clinical guidelines. The agency's National Guideline Clearinghouse (www.guideline.gov) has more than 1,000 guidelines currently on file.³

Still, many crucial questions remain unanswered. What percentage of clinicians, for example, would you guess actually make decisions for wound, ostomy, and continence patient care that are grounded in science rather than personal opinion? Do physicians, who are responsible for writing orders and overseeing patient care, have ready access to outcomes-based data - evidence to guide their decision? How strong should evidence be before it is integrated into clinical practice? Should clinical decisions be based on oral presentations of research findings, or should they be delayed until the data are actually published? How concerned should clinicians be about the composition of expert panels that develop guidelines for care? Should clinicians follow guidelines if they feel their specialty was not properly represented on the panel? To what extent does a clinician's specialty or experience (eg, WOC nurse) influence the outcomes of care?

In our country, clinical trials generate the evidence base used for decision making in all areas of medicine, including the establishment of health insurance payment and coverage policy. The quality of clinical trials (the backbone of medical research around which clinical practice is molded) has come under scrutiny by the government.⁴ Minorities, such as blacks and women, are often underrepresented in clinical trials. This limits informed decision-making by consumers as well as clinicians.