IMPLEMENTING THE REVISED AMERICAN PSYCHIATRIC ASSOCIATION PRACTICE GUIDELINE FOR THE TREATMENT OF PATIENTS WITH EATING DISORDER - 17/08/11
Résumé |
The late twentieth century will be remembered for many significant changes in the practice of medicine. Many of these changes stemmed from remarkable, welcome advances in science. For clinical medicine, these advances generally yielded a much higher quality of scientific evidence on which clinicians could base more effective practices. One result has been the rise of a movement called evidence-based medicine, which has achieved high ideological status in contemporary medical education and in professional societies, including the American Psychiatric Association (APA).8
At the same time, political, professional, institutional, and financial aspects of US medical practice have undergone substantial upheavals, characterized by increasing influences of managed care–related policies and procedures, with sometimes heavy-handed top–down management practices sharply shaping health care benefits. Managers started to control benefits and reimbursement for specific diagnoses and, within those diagnoses, carefully regulated the nature and frequency of outpatient visits, lengths of hospital stays, and details of treatments. They increasingly have determined the details of how medical care is provided by deciding how much they will pay (or if they will pay at all) for specific treatments, performed by specific types of providers, in specific settings, for specific diagnoses, accompanied by specific problems of specified severity and how closely they will monitor and regulate the provision of these services during the entire course of illness.
In theory, these management practices are intended to improve the efficient and effective allocation of resources available for health care and upgrade the general quality of medical practice through careful oversight. Sometimes this works. Through financial influences, managed care procedures generally have been able to reverse some previous practices that seemed wasteful, unnecessary, or excessive and that enriched physicians and institutions without notably adding to the health or well-being of those receiving care. However, in many instances, providers and patients have found the first generations of management practices to be arbitrarily restrictive, sometimes preventing individuals from receiving necessary care and not serving the best interests of the patient. Practitioners and patients often complained that the sometimes home-grown and often secretive sets of proprietary rules by which managed care utilization reviewers made their “clinical” decisions ignored important scientific information and the clinical wisdom of well-intentioned, experienced clinicians.
In response to these two complex trends, with a mushrooming evidence-based medical literature and the juggernaut of managed care, starting in the 1980s, professional societies increasingly jumped into the fray through efforts to preserve high-quality care and physician autonomy in clinical decision making. One result has been the explosive production of practice guidelines.12 Think of them as “scientific medicine meets political reality.”
By the early 1990s, thousands of practice guidelines had been produced. To help ensure that the guidelines being produced were of high quality and merited the confidence of medical practitioners and the public, the American Medical Association (AMA) established a partnership group involving all medical specialty societies and drew up detailed policies and procedures by which guidelines had to be developed and authoritatively reviewed if they were to pass muster and receive the sanction and blessing of the partnership. Policies and procedures developed by the Institute of Medicine (IOM) and the AMA require that investigators rate and make explicit the quality of the studies on which recommendations are based. In addition, practice guidelines must conform to five attributes, which are spelled out in considerable detail.4, 7 Briefly, the partnership guidelines should:
• | Be developed by or in conjunction with physician organizations |
• | Explicitly describe the methodology and process used in their development |
• | Assist practitioner and patient decisions about appropriate health care for specific clinical circumstances |
• | Be based on current professional knowledge and reviewed and revised at regular intervals |
• | Be widely disseminated |
The APA was far from the first specialty society to get involved in the AMA partnership or to produce guidelines, but the leadership of the association recognized that psychiatric patients, the public, mental health care professionals, and perhaps even insurance and managed care companies could all be well served by the production of high-quality practice guidelines concerning psychiatric diagnoses. The first APA practice guideline, published in 1993, addressed eating disorders.3 As per plan, each practice guideline of the APA is to be revised every few years to incorporate new advances and thinking in the field. Accordingly, the practice guideline for eating disorders was the first APA guideline to be revised, and the revision was published as a supplement to the American Journal of Psychiatry in January 2000.5
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| Address reprint requests to Joel Yager, MD Department of Psychiatry, University of New Mexico School of Medicine, 2400 Tucker NE, Albuquerque, NM 87131–5326, e-mail: jyager@unm.edu |
Vol 24 - N° 2
P. 185-199 - juin 2001 Retour au numéro
Article précédent
- PREFACE
- ARNOLD E. ANDERSEN
- EPIDEMIOLOGY AND MORTALITY OF EATING DISORDERS
- Søren Nielsen
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