Objective: To evaluate the long-term impact of an intervention designed to reduce the ordering of three tumor markers frequently prescribed for gastroenterologic diseases (carcinoembryonic antigen, alpha-fetoprotein, carbohydrate antigen 19-9).

Methods: A prospective study with time series analysis in a teaching hospital. Local clinical guidelines were developed and implemented through a new order form, designed as a reminder to the physician, restricting the ordering of laboratory tests. Ratios between the number of markers ordered and number of admissions were recorded during a 3-month period before and after intervention in the whole hospital and monthly on a 4-year period in two wards of the hospital (Department of Gastroenterology and Department of Internal Medicine). To evaluate the appropriateness of tumor marker orders, audits were performed on a sample of order forms, before and after (1 month and 2 years after) the implementation of the new order form.

Results: The analysis of covariance showed a significant effect of the intervention in the hospital (p < .01), and in the Departments of Gastroenterology (p < .01) and Internal Medicine (p < .007). The decrease of tumor marker orders ranged from 25% (Internal Medicine Department) to 55% (whole hospital). A similar decrease was observed for the three studied markers. The appropriateness of prescriptions increased from 54.6% before to 73.6% after the implementation of the new order form, but decreased to 52.9% 2 years after intervention.

Conclusions: Providing a reminder to clinicians through a specific order form represents an inexpensive and easy way to implement guidelines on use of laboratory tests.

Healthcare policy, medical practice, and cost of care are no longer considered distinctentities. Each is an integral factor in determining not only what, but how, patient carewill be delivered. Clinical practice guidelines are the lynchpin that connectsthem. This paper addresses the various components of the clinical practice guideline—cost alliance.

Objective: To examine the bidirectional influence of choice of care on costs and of cost of care on decision making.

Methods: The literature was used to identify cost-relatedfactors that influence development of guidelines and change in physician practicebehavior. In a MEDLINE search with modifiers to the keywords “clinical practiceguidelines,” particular attention was paid to identifying surveys of practitioners. Ananalysis, prompted by a recently published guideline, of treating penetrating intraperitoneal coloninjuries by different surgical approaches (primary repair versus diverting colostomy) exemplified how implementation of a guideline can affect the cost of care. Inpatientcost estimates, adjusted for medical inflation and cost-to-charge ratios and reported in1999 U.S. dollars, were developed using data from 1996 and 1997 discharge databases fromCalifornia and Massachusetts.

Results: The results showed that a substantial savings in hospital costs wasachieved when a primary repair surgical technique, as advocated by the guideline, was used. The effect of cost influences on the development of clinical practice guidelines wasestablished by demonstrating the cyclical effect between usual and customarypractices, guideline implementation, changing practice patterns, and the economicconsiderations influencing the process.

Conclusions: A growing, albeit uneasy, alliance between costs and clinical practice guidelines is evident.

In an effort to control ambulatory care costs, regulatory practiceguidelines (références médicales opposables or RMOs) wereintroduced by law in France in 1993. RMOs are short sentences,negatively formulated (“it is inappropriate to \ldots”), covering medical and surgical topics, diagnosis, and treatment. Since theirintroduction, physicians who do not comply with RMOs can be fined.The fine is determined by a weighted combination of indices ofharm, cost, and the number of violations.

The impact of the RMO policy on physician practice has been questioned, but so far few evaluations had been performed. At the end of 1997, only 121 physicians had been fined (0.1% of French private physicians). The difficulty of controlling physicians, the large number of RMOs, and the lack of a relevant information system limit the credibility of this policy.

The simultaneous development of a clinical guideline program to improve the quality of careand of a program to control medical practice can lead to a misunderstanding among clinicians and health policy makers. Financial incentives or disincentives could be used to change physician behavior, in addition to other measures such as education and organizational changes, if they are simple, well explained, and do not raise any ethical conflict. But these measures are dependent on the structure and financing of the healthcare system and on the socioeconomic and cultural context. More research is needed to assess the impact of interventions using financial incentives and disincentives on physician behavior.

A prospective audit study was undertaken to assess the effect of two different management policies following tonsillectomy in children in this hospital, one of which requires a prophylactic five-day course of oral antibiotics and the other does not. A total of 95 children were entered into the trial: 54 received post-operative antibiotics and 41 did not. The post-operative recovery was assessed by completion of a parent questionnaire which included the following parameters: degree of patient distress, nausea and vomiting, otalgia, halitosis, pharyngeal bleeding, analgesic requirement, day of return to a regular diet and General Practitioner consultation. There was no significant reduction in any of the morbidity measures in patients treated with antibiotics. In fact, the analgesic requirement and the incidence of otalgia and irritability on Days 6 and 7 and secondary haemorrhage were significantly higher in the antibiotic-treated patients. Although the number of patients included in this study are small, the results suggest that post-operative antibiotics do not improve the outcome of uncomplicated tonsillectomy. Our previous practice of routinely administering antibiotics to post-tonsillectomy children has been discontinued as the consequence of this audit.

Regional otolaryngological societies offer a valuable mechanism for the conduct of medical audit. The experience of the audit subcommittee of the Scottish Otolaryngological Society over the last few years is reviewed and a description is given of the findings of an audit of the management of laryngeal cancer in Scotland. The data collection infrastructure currently employed is described and emphasis is placed on the importance of ‘ownership’ of audit by those participating.