Objective:
To reduce testing among bospitalized patients using practice guidelines for any of 14 medical problems.
Design:Comparison of test use before and after implementation of guidelines. The guidelines were developed by consensus panels of
self-selected participating physicians. Non-participating physicians were monitored during the same periods. In addition,
the two groups of physicians were evaluated similarly for their management of three medical problems for which guidelines
were not developed.
Setting:Acute care hospital.
Patients/participants:1,638 hospitalized patients and their 79 physicians.
Intervention:Implementation of practice guidelines for the care of hospitalized patients.
Measurement and main results:Geometric mean charges expressed in inflation-adjusted dollars were used as measures of test use. For the intervention group,
laboratory tests decreased by 20.6%, x-rays by 42.3%, and EKGs by 34.2%. All the decreases were significant (p=0.001). The
non-participating physicians who were higher test users during both years of the study also achieved significant (p<0.05)
but smaller reductions during the intervention year: 13.9% for laboratory tests, 30.3% for x-rays, and 21.8% for EKGs, perhaps
because the same residents were involved in the care of both groups of patients. For the non-guideline diagnoses, the participating
physicians achieved reductions of 11.1% for laboratory tests and 19.2% for x-rays, and a 3.5% increase in EKGs. Two-way analyses
of variance that took into account the reductions in testing achieved by non-participants, or by participants with non-guideline
diagnoses, revealed no significant reduction in testing attributable directly to the guidelines except for EKGs. Follow up
of the participating physicians during the six months after the end of the intervention revealed that testing remained at
the lower level achieved while the guidelines were in use. Outcome of care, as measured by deaths in the hospital, deaths
within 90 days of discharge, and readmissions within 90 days of discharge, was not affected by the use of the guidelines.
Conclusions:1) A large group of physicians could be recruited in a hospital to establish practice guidelines by group consensus. 2) These
self-selected physicians were willing to use the guidelines (or allow the bousestaff to use them) while caring for their patients.
3) Participating physicians were able to achieve substantial and significant reductions in testing without any demonstrable
adverse effect on quality of care as measured by deaths and readmissions, and without any demonstrable shifting of resources
from the inpatient to the outpatient setting of care. 4) The reductions in testing, whether caused by the guidelines or not,
persisted for at least six months beyond the end of the period of implementation.
Key words practice guidelines - testing - cost - outcome
Received from the Division of General Internal Medicine, Rhode Island Hospital, Providence, Rhode Island.
Presented in part at the annual meeting of the Society of General Internal Medicine, Arlington, Virginia, April 27, 1989.
Supported by a grant from the National Fund for Medical Education.