Practice Policies in Anesthesia

Health care reform has become a subject of widespread popular discussion and impassioned national debate. Although most would agree that our system is too expensive, opinions differ widely as to the reforms that should be adopted to make health care less costly while maintaining its high quality. One proposed cost containment mechanism endorsed in several reform plans, including President Clinton's, is the expanded use of practice policies. Practice policies are systematically developed guidelines that seek to channel physician decision-making to pathways of proven clinical efficacy. Theoretically, the use of this strategy should reduce unnecessary care and therefore result in substantial savings without sacrificing quality. This paper will explore the history, development, effectiveness, and implications of practice policies in general and as they relate to anesthesia. The idea of practice standards in medicine is not new. In fact, almost all the generic rules, axioms, treatments, indications, and criteria in medical textbooks can be considered practice policies [1]. Consider this approach to the treatment of bronchitis practiced in Assyria 3500 yr ago: If the patient suffers from a hissing cough if his wind pipe is full of murmurs …, if he has phlegm: bray together roses and mustard in purified oil, drop it on his tongue, fill moreover, a tube with it and blow it into his nostrils. There-after he shall drink several times beer of the first quality; thus he will recover. [2] What is new today, and what has great implications for the way medicine will be practiced in the future, is the way practice policies are being produced and how they are being used. The informal, nearly anonymous, pronouncements made in old textbooks have been replaced by formal, highly exacting methodology for producing guidelines. Of even more concern to some physicians is the use of guidelines as regulatory tools imposed by those outside the medical profession. To these physicians the use of practice policies for quality assurance, utilization review, insurance coverage, and cost containment purposes by insurers, the government, and regulatory bodies is an erosion of the clinical autonomy of the medical profession. Others see the recent surge of interest in practice guidelines as the profession's best hope for accommodating the demands for quality care at the lowest possible price. Moreover, they see practice policies, not as a threat to autonomy, but as a valuable adjunct to the complex task of medical decision-making. As David Eddy observed: Practice policies present a powerful solution to the complexity of medical decisions. They free practitioners from the burden of having to estimate and weigh the pros and cons of each decision. They can connect each practitioner to a collective consciousness, bringing order, direction, and consistency to their decisions. 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