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  • ACOEM Applauds President Obama’s Efforts to Reform Health Care/Urges Adoption of National Guidelines

    June 16, 2009

    The Honorable Barack Obama
    President of the United States
    The White House

    Dear Mr. President:

    I am writing today on behalf of the American College of Occupational and Environmental Medicine (ACOEM) to commend you for comments regarding evidence-based medicine guidelines in your speech Monday, June 15, 2009 to the American Medical Association. As you continue your efforts to achieve meaningful health care reform, we respectfully ask that you consider the following points:

    • As the health care reform policy discussion continues, it will become increasingly important to clarify exactly what is meant by “evidence-based medicine” and “scientific evidence” when discussing medical practice guidelines. It is likely that various sectors of health care will define these terms in different ways during the coming debate – and these important concepts could easily be misconstrued or misapplied.
       
    • As the nation’s largest organization representing physicians who practice occupational medicine, and as the leading publisher of truly evidence-based medical guidelines for injured workers and musculoskeletal disorders, ACOEM has spent considerable time developing the most relevant, rigorous, reproducible, and transparent standards. We urge you and your administration to adhere to these or similar standards.

    To ensure that medical practice guidelines are credible, effective and minimally impacted by special interests, strict development standards must be in place. These standards include the following key attributes:

    • Strong, transparent methodology. The highest quality guidelines start with a transparent and rigorous methodology for decision-making which should adhere to general principles established and accepted by the medical community. Several medical organizations have published such standards for the development of guideline methodology, including the American Medical Association, the Institute of Medicine, and AGREE (an international collaboration).
       
    • Thorough review of scientific literature. For a set of guidelines to truly qualify as being evidence based, they should offer a well-documented review of all available scientific literature and a subsequent system that accurately judges the veracity and credibility of each study and evaluates the accumulated body of evidence. This means that the complete body of evidence related to various treatments must be considered – not simply evidence in support of targeted or preferred treatments. The process of compiling guidelines should be driven primarily by the question: “What is the quality of the evidence available, and what does it conclude?”
       
    • Multi-disciplinary input. High-quality occupational guidelines should be developed by multi-disciplinary panels, ensuring that multiple perspectives in health care are considered.
       
    • Emphasis on the highest scientific quality of evidence. The quality of evidence that results from medical-research studies varies widely. It depends on many factors, including the size of patient populations studied, the rigor of quality controls, and the study duration and data collection methods. It is generally acknowledged that the highest scientific quality of medical evidence comes from randomized controlled trials (RCTs), which best insure the validity of the results. The best guidelines, ones used to shape national policy, should be based as much as possible on RCTs as the highest standard of evidence, clearly defining and avoiding less rigorous forms of evidence and evidence summaries. This helps guide medical practice away from anecdotal, methodologically inferior evidence and propagation of unoriginal, selectively biased specialty guidelines.
       
    • A clearly defined process for interpreting situations of lesser quality evidence. Because high-quality RCTs are not available for every aspect of clinical care, a system of placing value on the evidence that is available must be clear. Value may be determined by generally considering the current standards and other options regarding treatments or tests, along with an analysis of the benefit or potential benefit, weighed against cost. The system used should be clearly described in the methodology supporting the guidelines.

    As you have already suggested in your public statements, evidence-based guidelines can make a difference in ensuring the best medical outcomes. The U.S. workers’ compensation system – one of the oldest social medical programs in the Nation – has also recognized the need for comprehensive, scientific, evidence-based guidelines and has been producing them for more than 12 years. In our experience, effective practice guidelines need to be part of an accepted standard of practice recognizing that many clinical situations cannot be addressed by a guideline and that appropriate care is best directed by knowledgeable physicians.

    We expect the trend towards the development and expanded use of guidelines to continue and intensify. But, for maximum effectiveness, there must be national standards for guidelines and they must be integrated into an expanded range of health IT products and services that allow point-of-care access and performance measurement, an essential ingredient for ultimate healthcare reform success.

    ACOEM applauds your public statements this week emphasizing the need to expand the use of scientific evidence-based guidelines and we urge you to continue to vigorously pursue this important component of health care reform.

    Sincerely,
    Eisenberg - new 
    Barry S. Eisenberg, CAE
    Executive Director
    ACOEM