J Oral Maxillofac Surg 57:1033, 1999

Developing a Scientific Basis For Clinical Care

Prior to the early 1980s a noncompetitive environ- ment offered few incentives to control the costs of health care. Patients had freedom of choice in select- ing their doctors and hospitals, doctors had freedom in selecting therapy, and the unlimited use of new diagnostic technology abounded. However, all of this began to change in the mid 1980s when federal and state governments, third-party payors, as well as employers who provided health care benefits to their employees, began to seek ways to control health care costs and to shift the financial risk to the providers and the patients. Among the major responses to this challenge was the development of practice guidelines, and the American Association of Oral and Maxillofa- cial Surgeons was a pioneer in this area, issuing its first AAOMS Parameters of Care document in 1992, its second in 1995, and now preparing the third edition for publication in 2000. True to the original promise, the development of these practice guidelines has been “ . . a continuous process that is driven by the existence of new information and the changing expec- tation of practitioners, patients, and the public.”

Although the development of practice guidelines was certainly an important step in the right direction, such guidelines do have their limitations. Whereas their use can be extremely helpful in reducing the costs of health care, they have limited usefulness in defining the value of such care, because of the alternative treatments that they present and the inabil- ity to ensure successful outcomes when these treat- ments are used. Unfortunately, the lack of randomized clinical trials to establish the efficacy of many of the proposed treatments has necessitated a reliance ‘on the opinions of panels of experts to establish the standards of care. However, to do such clinical trials is not only expensive and limited by ethical constraints, but also they often do not reflect the results obtained in the typical practice setting. An alternative approach is practice-based outcomes research in which the effectiveness of different strategies used by the aver- age practitioner for preventing and treating various conditions can be assessed. Although the current AAOM5 Parameters of Care provide criteria for judg- ing favorable therapeutic outcomes, they are unable to furnish the necessary information regarding which procedures lead to such outcomes. To address this

deficiency, AAOMS is now engaged in developing an outcome data collection system that will enable deter- mination of these parameters.

Such outcome studies are important for several reasons. Foremost, they are critical to the future control of our specialty. Without these studies, sound decisions about health care cannot be made by policy makers, governmental agencies, insurers, employers, and consumers. No longer can we rely solely on emotionally based and unsubstantiated claims to con- vince these groups that a particular therapy is indi- cated and reimbursable. Outcomes research can also help to establish the relative effectiveness of alterna- tive treatments for the same condition. For example, the current AAOMS study on third molars should finally provide the answer to the question regarding the prophylactic removal of asymptomatic impactions versus waiting to see if problems develop. Outcomes studies will also enable AAOMS to track changes in practice patterns over time, to predict future practice trends, to assess the impact of new technology and procedures, and, perhaps most importantly, to help practitioners make informed treatment decisions and improve their own performance and the quality of care.

Although AAOMS can establish the proforma for the collection of outcome data, collect the information, and monitor its accuracy, none of this is possible without the cooperation and support of our member- ship. The results of a survey distributed to approxi- mately 3,000 members in 1998 indicated that 91% of the respondents believed that AAOMS should supple- ment the Parameters of Care with a database that would permit the evaluation of clinical outcomes. Now is the time to f&ill this commitment by volunteer- ing to serve as a data collection site. Those who are not selected initially may have a future opportunity as different treatment modalities are evaluated. In the interim, we can all help to maintain clear standards of accountability by adhering to the current practice guidelines until further evidence-based information about treatment outcomes is available from these studies.

DANIEL M. LASKIN

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