The Opportunity Cost of Clinical Guidelines
Clinical guidelines translate research findings and expert opinion into recommendations for management of a specific disease, disease group, or health risk. There are thousands of guidelines in the National Guideline Clearinghouse, and updated and new ones are constantly added. In an ideal world all indicated guidelines would be followed for every patient, but implementing a new guideline often requires the expenditure of care and resources, including the use of time by both the patient and provider. From the patient perspective, the question remains: How many appropriate guidelines can any one patient follow? This is especially true for those with comorbidities and multiple indicated guidelines. From the provider perspective, similar questions arise: How many appropriate guidelines can be followed in one patient visit? Which are most beneficial? A growing number of guidelines and a fixed amount of time means that at some point not all guidelines can be implemented.
The decision of what to discontinue to be able to add a guideline is a difficult task. While some guidelines offer suggestions for managing a patient in the face of comorbidity (eg, hypertension in those with diabetes), guidelines do not help providers prioritize therapeutic options in patients with multiple diseases (eg, how do you prioritize heart failure recommendations in a patient with diabetes and chronic obstructive pulmonary disease?). In addition, guideline evaluations assess only the guideline's effects on disease-specific outcomes not its effect on the whole patient. This means the comparative effect on individual patient outcomes is unknown. Ensuring the care provided maximizes health benefits for each patient requires an accurate assessment by the provider of the value of the discontinued guideline. This entails forecasting individual patient outcomes across all health domains for every possible combination of guidelines, including those administered by other providers. Such an evaluation is clearly not possible for a provider to do on a patient-by-patient, appointment-by-appointment basis, but it is what the current guideline framework calls for.
There are potential ways to increase the supply of provider time to meet the additional demand for care imposed by a new guideline. These include lengthening the workday, improving efficiency (indeed, many guidelines help improve efficiency), and adding providers. However, there are natural limits to all these options; providers cannot work around the clock, efficiency has a natural limit (and guidelines are not usually designed with efficiency in mind), and underuse of the trained provider workforce is very low. So when providers are faced with new guidelines, they must decide what care to give in the time available. This requires removing other health care, which means the addition of a new guideline results in some care not being provided; care will be rationed. The discontinued care is the opportunity cost of implementing the new intervention.
Time as a Limited Resource
Clinical guidelines translate research findings and expert opinion into recommendations for management of a specific disease, disease group, or health risk. There are thousands of guidelines in the National Guideline Clearinghouse, and updated and new ones are constantly added. In an ideal world all indicated guidelines would be followed for every patient, but implementing a new guideline often requires the expenditure of care and resources, including the use of time by both the patient and provider. From the patient perspective, the question remains: How many appropriate guidelines can any one patient follow? This is especially true for those with comorbidities and multiple indicated guidelines. From the provider perspective, similar questions arise: How many appropriate guidelines can be followed in one patient visit? Which are most beneficial? A growing number of guidelines and a fixed amount of time means that at some point not all guidelines can be implemented.
The decision of what to discontinue to be able to add a guideline is a difficult task. While some guidelines offer suggestions for managing a patient in the face of comorbidity (eg, hypertension in those with diabetes), guidelines do not help providers prioritize therapeutic options in patients with multiple diseases (eg, how do you prioritize heart failure recommendations in a patient with diabetes and chronic obstructive pulmonary disease?). In addition, guideline evaluations assess only the guideline's effects on disease-specific outcomes not its effect on the whole patient. This means the comparative effect on individual patient outcomes is unknown. Ensuring the care provided maximizes health benefits for each patient requires an accurate assessment by the provider of the value of the discontinued guideline. This entails forecasting individual patient outcomes across all health domains for every possible combination of guidelines, including those administered by other providers. Such an evaluation is clearly not possible for a provider to do on a patient-by-patient, appointment-by-appointment basis, but it is what the current guideline framework calls for.
There are potential ways to increase the supply of provider time to meet the additional demand for care imposed by a new guideline. These include lengthening the workday, improving efficiency (indeed, many guidelines help improve efficiency), and adding providers. However, there are natural limits to all these options; providers cannot work around the clock, efficiency has a natural limit (and guidelines are not usually designed with efficiency in mind), and underuse of the trained provider workforce is very low. So when providers are faced with new guidelines, they must decide what care to give in the time available. This requires removing other health care, which means the addition of a new guideline results in some care not being provided; care will be rationed. The discontinued care is the opportunity cost of implementing the new intervention.