CMSA Today - Issue 8, 2012 - (Page 14)
Are “Best Practices” Really Best?
BY JOHN BANJA, Ph.D.
destabilize older guidelines in favor of newer ones. Most importantly, though, there is an appalling lack of good evidence to support many of the “best” practice guidelines that exist. Obviously, any organization such as the ones that case managers rely on to provide them with EBPs must look to good clinical research to justify EBPs. But how does one evaluate that clinical research when: • Diﬀerent studies on X — say, an intervention for pain — might use very diﬀerent measures to calculate “best,” such as medication safety, complication rates, side eﬀects, patient tolerance, patient satisfaction (that rely on subjective reports which can vary enormously from person to person), comparative costs, time to return to work, etc. Diﬀerent measures obviously confuse the meaning of “best” since you might be comparing apples to oranges. • Generalizing the results of a study can be dubious, such as when a cohort of research participants is very carefully chosen; but, once a drug or device is on the market, users might be vastly diﬀerent (in age, level of disease or morbidity, presence of co-morbidities, etc.) from the original research groups. • Researchers involved in many studies have pronounced conﬂicts of interest. Mehlman quotes data from a study of 17 cardiovascular guidelines issued by the American College of Cardiology and the American Heart Association. The study found that 277 of the 498 individuals who participated in developing the guidelines were paid consultants or advisory board members to commercial organizations, also received fees from speaker bureaus, owned stock, conducted
occasionally serve as an expert on medical malpractice cases and for some years have held the following opinion: If a health professional can prove that he or she followed a “best” or “evidence based” practice, then that should serve as a slamdunk defense in a malpractice proceeding against him or her. In other words, what the professional — whether he or she is a case manager, a physician, a nurse, etc. — owes the patient is the standard of care. And the best representation of that standard is the “best” or evidence based practice. So, if a professional is able to demonstrate in court that he or she practiced that standard, even though some harm unfortunately befell the patient, there should be no recovery for the plaintiﬀ.
However, after studying a recent article by law professor Maxwell Mehlman that appeared in the summer 2012 issue of the Journal of Law, Medicine and Ethics, I’m afraid my idea rests on a very dubious premise: That there really is an authentic, trustworthy, unassailable body of knowledge that represents what the “best” or evidence based practice (EBP) is. Mehlman argues that there isn’t, and here are some of his main points: If a best practice or evidence based guideline existed, then professionals
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should follow it religiously for the simple reason that it is the “best.” But that might make for bad policy because if the professional ever chose not to follow the guideline in a given case, he or she might have no defense if accused of malpractice. Put less dramatically, an insistence on following “best” practices can rob the professional of clinical discretion. Also, doggedly adhering to best practices or EBPs risks practicing outmoded medicine since research, which is always ongoing, tends to
Issue 8 • 2012 • DIGITAL
Table of Contents for the Digital Edition of CMSA Today - Issue 8, 2012
Transitions in Care
Passion in Case Management
Patient Assistance Programs
View from Capital Hill
Case Management and the Law
CMSA Corporate Partners
Index of Advertisers
CMSA Today - Issue 8, 2012