NEWS

Can Guidelines Be Integrated Into Everyday Practice? The NCCN in Year 4

Caroline McNeil

"Yesterday I sent a patient with biliary tract cancer to radiation oncology and asked, `Would this patient benefit from radiation therapy?' And the therapist came back and said, `What do the guidelines say?' "

This is a scenario to warm the heart of any guidelines writer, but it may not be a very common one — not yet anyhow. Clinical guidelines, whether in oncology or other areas of medicine, are notorious for their lack of impact on actual practice.

In this case, the speaker is William Burak, M.D., assistant professor of surgery at the Arther G. James Cancer Hospital, Ohio State University Medical Center in Columbus, and the guidelines are those of the National Comprehensive Cancer Network, a consortium of cancer centers that set out 4 years ago to create consensus-based clinical guidelines for oncology.

The NCCN has done that — guidelines for 34 different cancers and related conditions since 1995 plus updates and screening guidelines. But it now faces the even more formidable task of integrating the guidelines into actual practice.

Massive Undertaking

"This is a massive undertaking," said John L. Wilson, Ph.D., director of outcomes management at Ohio State, who spoke at the NCCN's 4th annual meeting in Fort Lauderdale, Fla., in March. "The [guideline] effort equals 10% writing, 90% implementation."

A number of NCCN institutions are now tackling that remaining 90%. What will work — what could make that Ohio State scenario more common — is probably a combination of factors, according to interviews with clinicians and others involved with the NCCN guidelines. These factors include the feedback on guideline adherence provided by the nascent NCCN database; the close involvement of physicians in each institution in writing and implementing the guidelines; and administrative supports that make them part of an institution's existing infrastructure.

One thing that does not work, according to experts, is education alone. Various studies have shown that simply telling people about guidelines has little effect, said Jerome Yates, M.D., Roswell Park Cancer Institute, Buffalo, N.Y., and Rodger Winn, M.D., University of Texas M. D. Anderson Cancer Center, Houston. Typical is a Canadian study of guideline adherence by obstetricians and gynecologists, Winn said. "They all knew the guidelines but it didn't modify behavior."



View larger version (149K):
[in this window]
[in a new window]
 
Dr. Rodger Winn

 
James Montie, M.D., has had first-hand experience with this fact of clinical life in the urology department he heads at the University of Michigan, Ann Arbor, one of the 17 NCCN member institutions. Montie said that clinicians in his department had little interaction with the NCCN prostate cancer guidelines until an internal study of adherence to the guidelines got under way. Now, as part of that study, a copy of the guidelines accompanies patient charts at each visit and the physician notes on a form where the patient is on the guideline pathway.

"Without that, it would be common for physicians to agree in concept and know the general layout of the guidelines but not be familiar with the details and not really use them," Montie wrote in an e-mail. "Evaluation of the adherence to the guidelines will be where the learning process for doctors and hospitals will occur."

To Change Behavior

NCCN leaders agree, saying that on-going evaluation and feedback on guideline adherence is a key objective. "Using outcome data to monitor compliance with guidelines is a critical component to providing the feedback that's actually going to change behavior," said Jane Weeks, M.D., of the Dana Farber Cancer Institute in Boston, speaking at an earlier NCCN meeting.



View larger version (145K):
[in this window]
[in a new window]
 
Dr. Jane Weeks

 
Weeks is heading the consortium's effort to build a database that eventually should allow feedback and evaluation on a large scale. According to the vision for this project, it will provide feedback to every NCCN institution on how its patients are diagnosed, treated, and followed as well as data on its adherence to the guidelines and on patient outcomes. These data, so the theory goes, will then alert institutions to practice patterns that may need attention.

The database has just passed its first test, Weeks said, supplying proof of this general principle. She presented the initial results from a pilot project in which breast cancer data from five NCCN institutions were collected in the database, analyzed, and reported back to the institutions. One thing the data showed was a definite variation among the five centers in the use of lumpectomy plus radiation for early stage disease (the guidelines state that lumpectomy plus radiation is "preferred" in stages I and II).

After feedback from the NCCN database, however, data from the same centers now indicate their use of lumpectomy is growing more uniform. This suggests that the feedback mechanism is working as envisioned, Weeks said.

The database project, besides encouraging adherence to the guidelines, is having an impact on practice in other ways. For one thing, database participation means more intense data collection, Burak said, particularly on quality of life associated with different treatments, such as days lost from work and functional status. At Ohio State, patients now fill out a quality of life questionnaire at every visit.

The resulting outcomes information may also make a difference in day-to-day practice. "When I'm talking to a patient, I will be able to give her not only expected survival but also some idea of what her quality of life will be," Burak said. "We have never had that."

Outcomes data may also change life for some NCCN clinicians when it comes to dealing with insurance companies. In Buffalo, N.Y., for instance, third-party payers have shown some interest in allowing use of the NCCN guidelines to replace preauthorization of certain procedures, said Yates, who is vice president for clinical affairs at Roswell Park. That is, if guidelines are in place and Roswell Park can demonstrate adherence, the companies would no longer require clinicians to obtain prior approval for procedures.

Administrative Supports

While the database may be the linchpin of the NCCN's effort to implement the guidelines, more is needed, say experts. "Outcome information is important but not enough," said Yates. "You need to give administrative support." That can range from making guidelines accessible on a center's computer network to setting up an entire system "that in essence mandates compliance with guidelines," said Winn.

Some of the strongest administrative supports may be those just instituted at M. D. Anderson, which is using the NCCN guidelines for preauthorization of procedures under a new disease management program called Cancer ManagerTM. Oncologists now call a case manager (an oncology nurse) to get authorization to go ahead with a procedure, according to Winn, who is chief of the community oncology section at M. D. Anderson. The case manager checks the NCCN guidelines before giving an okay. If the physician says there is a reason not to follow the guidelines, the decision is bumped up to a medical director.

Winn said that while this system is now simply responsive to calls from oncologists — "a 1-800-mother-may-I system" — he hopes eventually to add a tickler component. For example when a patient has surgery for rectal carcinoma, the system would check that it was followed up by radiation therapy. If not, a red flag in the computer would prompt the manager to check with the physician.

Another place where an entire system is evolving to operationalize the guidelines is Ohio State. Wilson, described a system that revolves around the active involvement of physicians in both writing and implementing the NCCN guidelines. This is a system that the NCCN framework itself supports, since every member institution has to assign physicians to work on writing each set of guidelines.

But at Ohio State, these guideline authors are responsible for much more. They also shepherd the guidelines through various internal review groups, put the final, approved versions into the medical center's own format, and then draw up a detailed implementation plan, including strategies for measuring compliance and patient outcome.

The guidelines are published on the medical center's computer network, presented at tumor board and case management meetings, and given to point-of-care contacts, Wilson said. "We also put them in a nice little pocket notebook," he said, "but I'm afraid these may end up on a shelf most of the time."

In fact, dissemination of the guidelines represents only the beginning of the implementation process, Wilson said, and physicians assigned to write the NCCN guidelines must continue to be involved. "I think it's important to note that to realize the potential of the guidelines, hospital physicians must be involved in leadership roles, not merely tolerant or cooperative," Wilson said.



             
Copyright © 1999 Oxford University Press (unless otherwise stated)
Oxford University Press Privacy Policy and Legal Statement