Topic last updated Aug. 2006
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Addressing Issues
Professional Training: Preparing
Health Care Professionals for Systems Change
Different
Levels of Practice Recommendations
The rigor with which change is sought in existing clinical practices
must be tempered by the strength of data supporting the change.
Three
levels of recommendations currently exist - standards of care that must be followed in almost all cases, practice
guidelines that are followed in most cases, and treatment options that are at the health care professional's discretion.2
- Standards
of care are practice recommendations that must be followed
in virtually all cases. Providers need to document reasons for
any deviation — for example, if aspirin was not given early in the
treatment of an acute myocardial infarction because of an existing
allergy. There is unanimity of opinion among experts that
standards of care are the best clinical recommendations. The health and
sometimes even the economic consequences of these standards are
well known. "Strict" indications or contraindications
exist that make them clearly "appropriate" or "inappropriate"
practices. Very few interventions rise to this level.
- Practice Guidelines
represent recommendations that should be followed in most cases.
They are intended to be more flexible than standards of care, with deviations being fairly
common. Deviations are justified by a difference in circumstance
and patient preference. Practice guidelines represent what an appreciable
majority of health care professionals believe and are tailored to fit the
individual needs of patients. Only "relative" indications
and contraindications exist for their implementation. For example, practice guidelines help health care professionals make appropriate decisions with
patients about starting ACE inhibitors to prevent progression
of renal disease in people with diabetes, or about the frequency
of blood glucose monitoring to optimize metabolic control.
- Treatment
options are practices for which the literature, when critically
appraised, is neither supportive of nor critical of a particular
clinical intervention. It is important for health care professionals to be aware
of available options for interventions, but they are free to choose
any appropriate course.
When
working to improve the implementation of standards of care, education
should focus on "how" the standards can best be carried
out within the clinical setting - especially within the political
culture. When guidelines are being promoted, education needs to
focus on both the "how" and the "why" of
the proposed clinical improvement. Education about treatment options
should focus on awareness of new developments.
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