US Institute of Medicine recommends new body to assess what works in health care Summarised by Malcolm Macpherson from an article by Janice Hopkins Tanne, in the British Medical Journal, 2nd February 2008 Commentary at foot The Institute of Medicine, part of the US National Academy of Sciences, recommended last week that the country needs an independent program to evaluate "which diagnostic, treatment, and prevention services work best for various patients and circumstances." The institute's report proposes a single entity to provide "credible, unbiased information." It would be overseen by an advisory board "constituted to minimize bias," and its scope seems to be similar to that of the United Kingdom's National Institute for Health and Clinical Excellence (NICE). Under the status quo, the quality of systematic reviews is variable and findings are often unreliable even when published in peer-reviewed scientific journals, the report says. Hundreds, even thousands, of competing guidelines exist, and there is uncertainty about which are reliable and objective. Guidelines that are paid for by manufacturers or vendors, as many are, are more likely to show effectiveness. Unfortunately, the current processes underlying guideline development are often vulnerable to bias and conflict of interest. Overall, the quality of clinical practice guidelines is often poor, the report says. The report was sponsored by the non-profit Robert Wood Johnson Foundation. It says that the US Congress should establish a single national clinical effectiveness program with sufficient resources, authority, and capacity to facilitate the development of standards and processes that yield credible, unbiased, and understandable syntheses of the available evidence on clinical effectiveness. The highest priority should go to clinical questions of patients and clinicians that have the potential for substantial impact on health outcomes across all ages, burden of disease, health disparities, and undesirable variation in the delivery of health services, the report says. The new program is needed because spending on ineffective as well as effective treatments contributes to soaring health costs and rising insurance premiums. Furthermore, healthcare providers often disagree on treatments and clinical practice standards, the report says. Patients and insurance plans cannot always be assured that providers are delivering the best, most effective care. Health [insurance] plans are burdened with the need to constantly learn how their covered populations might benefit from or be harmed by newly available health services, it says. The institute's committee was chaired by Barbara McNeil, professor and head of the department of healthcare policy at Harvard Medical School and professor of radiology at Brigham and Women's Hospital in Boston. She said that the program would enable us to sort the wheat from the chaff and make sense of it all. The committee outlined three steps towards evaluating evidence of effective healthcare services: "Setting priorities for evidence assessment, assessing evidence through systematic reviews, and developing (or endorsing) standards for trusted clinical practice guidelines." It said that Congress should direct the US secretary for health and human services to create a programme with resources and capability to evaluate clinical effectiveness. The programme should be overseen by an advisory board constituted to minimize bias and should have representation from public and private sector interests. The programme should report annually to Congress. Commentary Reads a bit like re-inventing the wheel in a landscape overrun with wheels. If this proposal were to get serious attention in the sector in the US, then a great place to begin would be with the small group of health service providers with a record of success in the health excellence field-the State and Federal recipients of Baldrige Awards! That's where effective work on defining and publishing the 'vital few' measures has already been done, and where systematic process diagnosis has focused the organisations (hospitals, regional funders and plan managers) on what matters and what works. The Brilliant New Zealand Ltd solution: Conduct an organisation-wide diagnosis, structured to be inclusive and exhaustive, using a set of well-established universally-applicable criteria Commit to implementing the opportunities for improvement revealed by this diagnosis, again using well-established processes, centred on three lines of improvement: - minimising variation - minimising waste - designing-in appropriate balance