Guidelines As Rationing Tools: a Qualitative Analysis of Psychosocial Patient Selection Criteria for Cardiac Procedures

Overview

Journal CMAJ

Date 2001 Mar 22

PMID 11258209

Citations 4

Authors

M K Giacomini

D J Cook

D L Streiner

S S Anand

Affiliations

Soon will be listed here.

Abstract

Background: Cardiac procedure guidelines often include psychosocial criteria for selecting patients that potentially introduce social value judgements into clinical decisions and decisions about the rationing of care. The aim of this study was to investigate the terms and justifications for and the meanings of psychosocial patient characteristics used in cardiac procedure guidelines.

Methods: We selected English-language guidelines published since 1990 and chapters in textbooks published since 1989. These guidelines amalgamated multiple sources of evidence and expertise and made recommendations regarding patient selection for specific procedures. A multidisciplinary team of physicians and social scientists extracted passages regarding psychosocial criteria and developed categories and conceptual relationships to describe and interpret their content.

Results: Sixty-five papers met the criteria for inclusion in the study. Forty-five (69%) mentioned psychosocial criteria as procedure indications or contraindications. The latter fell into several categories, including behavioural and psychological issues, relationships with significant others, financial resources, social roles and environmental circumstances.

Interpretation: Psychosocial characteristics are portrayed as having 2 roles in patient selection: as risk factors intrinsic to the candidate or as indicators of need for special intervention. Guidelines typically simply list psychosocial contraindications without clarifying their specific nature or providing any justification for their use. Psychosocial considerations can help in the evaluation of patients for cardiac procedures, but they become ethically controversial when used to restrict access. The use of psychosocial indications and contraindications could be improved by more precise descriptions of the psychosocial problem at issue, explanations regarding why the criterion matters and justification of the characteristic using a biological rationale or research evidence.

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References

Tanenbaum S . Knowing and acting in medical practice: the epistemological politics of outcomes research. J Health Polit Policy Law. 1994; 19(1):27-44. DOI: 10.1215/03616878-19-1-27. View

LINDESMITH G . Practice guidelines in cardiothoracic surgery. Ann Thorac Surg. 1992; 53(5):930-9. DOI: 10.1016/0003-4975(92)91477-q. View

. Angioplasty standard of practice. Standards of Practice Committee of the Society of Cardiovascular and Interventional Radiology. J Vasc Interv Radiol. 1992; 3(2):269-71. View

. Practice guidelines for pulmonary artery catheterization. A report by the American Society of Anesthesiologists Task Force on Pulmonary Artery Catheterization. Anesthesiology. 1993; 78(2):380-94. View

Olbrisch M, Levenson J . Psychosocial evaluation of heart transplant candidates: an international survey of process, criteria, and outcomes. J Heart Lung Transplant. 1991; 10(6):948-55. View

Swan H . Guidelines for judicious use of electrocardiography. A summary of recommendations from the ACC/AHA Task Force Report. J Crit Illn. 1992; 7(6):861-70. View

Costanzo M, Augustine S, Bourge R, Bristow M, OConnell J, Driscoll D . Selection and treatment of candidates for heart transplantation. A statement for health professionals from the Committee on Heart Failure and Cardiac Transplantation of the Council on Clinical Cardiology, American Heart Association. Circulation. 1995; 92(12):3593-612. DOI: 10.1161/01.cir.92.12.3593. View

. Guiding principles on human organ transplantation. World Health Organization. Lancet. 1991; 337(8755):1470-1. View

Fitzpatrick A, Sutton R . A guide to temporary pacing. BMJ. 1992; 304(6823):365-9. PMC: 1881239. DOI: 10.1136/bmj.304.6823.365. View

10.

Washington R, Bricker J, Alpert B, Daniels S, Deckelbaum R, Fisher E . Guidelines for exercise testing in the pediatric age group. From the Committee on Atherosclerosis and Hypertension in Children, Council on Cardiovascular Disease in the Young, the American Heart Association. Circulation. 1994; 90(4):2166-79. DOI: 10.1161/01.cir.90.4.2166. View

11.

Majeske R . Transforming objectivity to promote equity in transplant candidate selection. Theor Med. 1996; 17(1):45-59. DOI: 10.1007/BF00489740. View

12.

Wilson M, Hayward R, Tunis S, Bass E, Guyatt G . Users' guides to the Medical Literature. VIII. How to use clinical practice guidelines. B. what are the recommendations and will they help you in caring for your patients? The Evidence-Based Medicine Working Group. JAMA. 1995; 274(20):1630-2. DOI: 10.1001/jama.274.20.1630. View

13.

. Catheter ablation for cardiac arrhythmias: clinical applications, personnel and facilities. American College of Cardiology Cardiovascular Technology Assessment Committee. J Am Coll Cardiol. 1994; 24(3):828-33. DOI: 10.1016/0735-1097(94)90036-1. View

14.

Hughes D, Griffiths L . "Ruling in" and "ruling out": two approaches to the micro-rationing of health care. Soc Sci Med. 1997; 44(5):589-99. DOI: 10.1016/s0277-9536(96)00207-9. View

15.

Lewis S . Paradox, process and perception: the role of organizations in clinical practice guidelines development. CMAJ. 1995; 153(8):1073-7. PMC: 1487324. View

16.

. Guidelines for percutaneous transluminal angioplasty. Standards of Practice Committee of the Society of Cardiovascular and Interventional Radiology. Radiology. 1990; 177(3):619-26. DOI: 10.1148/radiology.177.3.2147067. View

17.

DREIFUS L, FISCH C, GRIFFIN J, Gillette P, Mason J, Parsonnet V . Guidelines for implantation of cardiac pacemakers and antiarrhythmia devices. A report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on.... J Am Coll Cardiol. 1991; 18(1):1-13. DOI: 10.1016/s0735-1097(10)80209-8. View

18.

Levine A, Levine T . Patient evaluation for cardiac transplantation. Prog Cardiovasc Dis. 1991; 33(4):219-28. DOI: 10.1016/0033-0620(91)90027-j. View

19.

Grimshaw J, Hutchinson A . Clinical practice guidelines--do they enhance value for money in health care?. Br Med Bull. 1995; 51(4):927-40. DOI: 10.1093/oxfordjournals.bmb.a073006. View

20.

. ACC/AHA guidelines and indications for coronary artery bypass graft surgery. A report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Subcommittee on.... Circulation. 1991; 83(3):1125-73. DOI: 10.1161/01.cir.83.3.1125. View