From the Journal of the Canadian Medical Association:Time to Weed the CPG garden (CMAJ editorial)
Further Disquiet on the Guidelines Front
Steven J. Lewis
Promoting Effective Guideline Use in Ontario
Walter W. Rosser, Dave Davis, Erin Gilbart, on behalf of the Guideline Advisory Committee
What Is the Quality of Drug Therapy Clinical Practice
Guidelines in Canada?
Ian D. Graham, Susan Beardall, Anne O. Carter, Judith Glennie, Paul C.Hébert, Jacqueline M. Tetroe, Finlay A. McAlister, Silvia Visentin, Geoffrey M. Anderson
High-quality clinical practice guidelines have the potential to improve care and patient outcomes. Ian Graham and authors used a standardized guideline appraisal instrument to assess the quality of 217 guidelines related to drug therapy developed or endorsed by Canadian organizations from 1994 to 1998. Each guideline was scored by three appraisers on the rigour of the development process, the context and content, and the application or implementation of the guidelines. Overall, 64.6% of the guidelines were recommended with modification by at least two of the three appraisers, 9.2% were recommended without change, and 26.3% were not recommended. Quality varied significantly by developer, publication status and drug company sponsorship, and no substantial improvement in quality was observed over the five-year study period. Steven Lewis comments on the appraisers' expectations and the ongoing challenge of implementing guidelines. A second commentary, by Walter Rosser and associates from the Guideline Advisory Committee, describe their efforts to identify and promote the use of well-developed guidelines in Ontario.
From the British Medical Journal:Comparative Efficiency of National Health Systems: Cross National Econometric Analysis
David Evans, Global Programme on Evidence for Health Policy, World Health Organisation, Geneva, Switzerland
Editorial: Measuring The Efficiency of Health
Martin McKee, Professor of European Public
Health, London School of Hygiene and Tropical Medicine, London, UK
Countries with the best levels of health do not always have efficient health systems, according to a study in BMJ, which ranks the health systems of the world according to their efficiency in turning expenditure into health. Researchers at the World Health Organisation estimated the efficiency of health systems in 191 countries, using data from 1993-1997. After taking account of the level of education in the population, they then ranked the health systems of each country according to their efficiency in turning expenditure into health. Estimated efficiency varied from nearly fully efficient to nearly fully inefficient, implying that although some countries may be close to their potential, others are not reaching anywhere near maximum levels of health, explain the authors.
Despite its many limitations, the report has achieved something, argues Professor Martin McKee in an accompanying editorial. It has exhorted governments to take a much more active role in promoting health. It has provided a useful conceptual framework that begins to tease out the goals of health systems, and it has emphasized the need for a much better understanding of the undoubted impact that health systems have on health.
From the Journal of the American Medical Association:Estimating Hospital Deaths Due to Medical Errors
Preventability Is in the Eye of the Reviewer
Rodney A. Hayward, MD; Timothy P. Hofer, MD, MS
Recently reported estimates of the number of deaths in US hospitals due to medical error have been extremely high, but the validity of these estimates has been questioned. In this study by Hayward and Hofer of 111 in-hospital deaths at seven Veterans Affairs medical centers, physician reviewers rated whether deaths could have been prevented by better medical care, and estimated the probability that the patient would have lived to discharge or for three months or more in good cognitive health had care been optimal. Almost 23% of in-hospital deaths were rated as at least possibly preventable by optimal care, similar to that reported in prior studies. But the estimate of the percentage of patients who died who would have left the hospital alive had optimal care been provided was 6%, and the estimate of the percentage of patients who would have lived three months or more in good cognitive health, after adjusting for variability and skewness of reviewer ratings, was only 0.5%.
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