Hospitals Under Pressure to Adopt Cancer Guidelines

SAN DIEGO--Hospitals are facing tremendous pressures from theinsurance industry to standardize treatments by adopting clinicalpractice guidelines, panel members said at a conference sponsoredby the Society for Ambulatory Care Professionals and Health TechnologyAssessment of the American Hospital Association.

As a practical matter, hospitals contemplating the developmentof their own guidelines do not have to be as exhaustive in theirresearch as some of the professional societies, said Rodger J.Winn, MD, chief of the section of community oncology at the Universityof Texas M.D. Anderson Cancer Center, and chairman of the GuidelinesCommittee of the National Comprehensive Cancer Network (NCCN).

But on the flip side, he warned, guidelines development must bebased on objective sources and not merely standardize currentpractice. "Don't simply ask a couple of surgeons at yourhospital to draw up procedures based on what they do in the operatingroom," he said.

The most rigorous method of guidelines development is to pursuean evidence-based consensus. "You look at all the literatureand then grade each study," Dr. Winn said, but he also suggesteda shortcut to this process.

"Bring together experts, including subspecialists, in a room,"he said. "They will know the four or five trials that arethe most pertinent. You don't have to look at all 12,000 articlesin the literature--they know the five that really shape the decision."Let these experts develop the guidelines, Dr. Winn said, and thensend the document out to a dozen other experts for feedback.

This was the type of procedure used by the guidelines committeeof the National Comprehensive Cancer Network, Dr. Winn said. TheNCCN is a consortium of 15 major cancer centers that has developedpreliminary guidelines for eight of the most common neoplasmsand is currently devising eight additional site-specific pathways.

Dr. Winn also stressed the importance of developing goals fromthe beginning. "If you don't decide on the outcomes up front,you can never do the guidelines at the end." Goals for shorterhospitalization could result in one set of treatment recommendations,while targeting longer survival of cancer patients could resultin another, he said.

Ideally, guidelines should assist in decision making. For example,a patient newly diagnosed with colon cancer is found to have livermetastases. With 8 months or so to live, should a surgeon operateon this patient? "The surgeons say you apply clinical judgment--youlook at the patient and decide," Dr. Winn said. "Butthis is a situation where guidelines could begin to come intoplay."

The guidelines might spell out the criteria for when surgery shouldbe performed based on how much liver disease is present or thediameter of the colon. "Maybe we can begin to get rid ofsome of the subjectivity of decision making," Dr. Winn commented.

Once adopted, guidelines will undoubtedly be ignored if an institutiondoesn't make a major effort to implement them. Dr. Winn citedthe experience of the Canadian health system when it releasedits guidelines to cut down on repeat caesareans. The guidelinesstate that if a woman has already undergone one caesarean, shedoesn't automatically need the procedure performed again.

A year later, a survey indicated that 98% of physicians knew aboutthe guidelines and 87% agreed with them. What's more, 67% of theobstetrician/gynecologists said they did fewer repeat C-sectionsbecause of the guidelines.

The patient charts, when pulled, told a much different story,Dr. Winn noted. "There was zero effect. The guidelines didn'tchange any habits. Thus, education alone is not enough to ensurethat guidelines are followed."

Dr. Winn thinks the "toughest nut to crack" in implementingany set of oncol-ogy guidelines will be when to stop treatment.Guidelines will need to specify the circumstances in which conventionaltherapy can be considered to be exhausted and patients shouldreceive best supportive care or enter a clinical trial.