Evidence-Based Medicine, Critical Pathways, Practice Guidelines, and Managed Care

Abstract

Because managed care plans are exerting enormous pressure to reduce the cost of medical care, neurologists need to enhance their skills at identifying appropriate, high-quality, and cost-effective care for patients with neurological disorders. A variety of health services research methods are available that foster evidence-based decisions and de-emphasize intuition in decision making. Despite imperfect data and a lack of familiarity with some of these methods, we have found them useful in developing guidelines and pathways for the prevention and management of stroke. Neurologists should become more familiar with the pragmatic benefits, limitations, and obstacles that hinder acceptance and implementation of these approaches. If we wish to continue to influence the medical decision process, we must focus on the provision of quality neurological care and not on the managed care plan.

Care pathways for acute stroke care and stroke rehabilitation: From theory to evidence

“…91 It is therefore common to find that care pathways are introduced as part of an overall quality improvement scheme, rather than as a stand-alone organisational intervention. 92 For example, acute stroke care pathways may be introduced as part of a multi-faceted program consisting of a number of objectives such as to improve the accuracy of pre-hospital diagnosis of stroke, to speed up the transfer of patients to hospital for emergency treatments such as thrombolysis, to improve the efficiency of triage and assessment of patients with suspected stroke, including emergency neuroimaging for those who might be eligible for thrombolysis.…”

Psychosocial intervention in stroke: Families in recovery from stroke trial (FIRST).

“…Although there is evidence that integrated rehabilitation efforts are effective in promoting recovery from stroke (Reding & McDowell, 1989), a surprising lack of research in this area has left many questions about optimal rehabilitation strategies unanswered. With ever-increasing numbers of patients enrolled in managed care plans, the rehabilitation process is becoming more likely to take place outside the hospital environment (Retchin, Brown, Yeh, Chu, & Moreno, 1997; Ringel & Hughes, 1996), leading to considerable interest in low-cost, noninvasive interventions for facilitating rehabilitation after hospital discharge.…”

Quality of Neurological Care

“…Costcontrol considerations should be a legitimate part of these guidelines because of the duty to conserve costs. 43 Physicians at the bedside also should consider the costs of the care they provide and make responsible decisions that further their patients' interests but do not squander resources. These decisions include cost-conscious bed¬ side professional judgments considering marginal util¬ ity and value.44"46 Physicians should advocate for pro¬ viding care of benefit to patients but refrain from ordering tests or treatments of little or no benefit.…”