Forum Focus – A new alternative to clinical practice guidelines

Physicians at Boston Children’s Hospital have created a new alternative to clinical practice guidelines that allow for more flexibility, narrow practice variability, all the while letting clinicians tailor treatments to an individual patient’s needs. Called Standardized Clinical Assessment and Management Plans (SCAMPs), they also aim to optimize resources, improve patient care, reduce costs and keep pace with changing medical knowledge. An article (abstract only) published in the May 2013 issue of Health Affairs provides more details about SCAMPs. A summary of the article follows.

The need for change

Although clinical practice guidelines are intended to reduce variation and improve care, one of their main shortcomings is they do not account for individual and personal preferences among patients. The following of ridged guidelines may also reduce the autonomy of physician practice. Other shortcomings include the limitations clinical studies have in forming the foundation for the guidelines, and medical evidence used to form the basis of the guidelines usually has a short shelf life. Physicians at Boston Children’s Hospital thought there had to be a better way. This is how they came up with SCAMPs.

Creating a SCAMP

Developing and modifying a SCAMP involves eight steps and is led by a multidisciplinary group of clinicians.

  1. A group formulates a background paper on a particular disorder, examining the medical literature and relevant professional society guidelines in order to establish a foundation for sound clinical practice.
  2. Modeled on the processes/standards used to create practice guidelines, the group reaches a consensus on which patients to include in the SCAMP, what clinical assessments to include and how to structure the treatment methods.
  3. The group identifies what data will be collected to inform knowledge gaps that may exist.
  4. Electronic forms/tools are created to collect the data.
  5. The SCAMP is then piloted at a few sites before being deployed on a larger scale. A data coordinator helps with patient enrollment. Clinicians see and treat patients, in general, according to the appropriate SCAMP protocol, but are free to vary from the protocol for any reason, as long as he or she documents why they diverted from the protocol. The clinician makes sure to collect and record data on the patient, including the reason for diversions.
  6. A data coordinator gathers the information collected by the clinicians, as well as additional relevant information from the patient’s electronic health record. All of this information is stored in a database.
  7. After a period of six to 12 months, or a minimum of 200 patients have been enrolled, a statistician analyzes the data. The report is reviewed by the clinical group, as well as all of the clinicians participating in the SCAMP.
  8. Using data from the report, including the diversions, and new medical literature, the SCAMP is then modified for future use.

Results

From early 2009 until the publishing of the Health Affairs article, more than 12,000 patients were enrolled in 49 SCAMPs in nine states and Washington, D.C. One study found clinician adherence to SCAMP protocols has exceeded 80 percent. Another analysis found that revising the SCAMP criteria for a genetic specialist referral on pediatric patients with a dilated aorta rose from 19.6 percent to 75 percent. Boston Children’s own analysis on six episodes of care where a SCAMP was implemented showed an 11-51 percent decrease in total medical expenses.

Conclusion

SCAMPs have shown to be a viable alternative to clinical practice guidelines. Because of their design, SCAMPs allow for a more flexible approach when it comes to patient care and clinician adherence, as diversions are permitted. They are routinely examined and modified to stay current with the growth of medical knowledge, thus ensuring high quality care is delivered using the appropriate amount of resources.

“SCAMPs have proved to be a very useful tool for many clinical scenarios, where there is insufficient information to inform medical decisions,” said Kathy Jenkins, MD, MPH, Senior Associate in Cardiology, Senior Vice President, Chief Safety and Quality Officer, Boston Children’s Hospital, and Professor of Pediatrics, Harvard Medical School. “SCAMPs allow rapid progress to reduce unnecessary resource utilization, while improving care delivery.”  

For more information on SCAMPs, contact Kathy Jenkins at Kathy.Jenkins@CARDIO.CHBOSTON.ORG.