Most deviations from guidelines for medical reasons are appropriate

ST LOUIS (MD Consult) - In the vast majority of cases, physicians' deviation from quality measures set forth in guidelines on medical grounds are appropriate, finds a single-institution study reported in the February 16, 2010, issue of the Annals of Internal Medicine. Investigators implemented a system in a large internal medicine practice to allow physicians to document medical exceptions to 16 quality measures pertaining to preventive care and the management of chronic disease, to peer review the exceptions recorded, and to provide feedback to the physicians.

A peer review panel classified each medical exception as appropriate, inappropriate, or of uncertain appropriateness.

During a 7-month period, physicians recorded 614 exceptions to quality measures for medical reasons.

The panel classified 94% of the exceptions as medically appropriate, 3% as inappropriate, and 3% as having uncertain appropriateness.

Of the 19 exceptions found to be inappropriate, 10 pertained to diabetes care, 7 pertained to coronary heart disease care, 2 pertained to preventive services, and none pertained to heart failure care.

After provision of feedback, physicians altered their management in 8 (42%) of the 19 cases.

Less than 5 minutes was required to peer review each case. However, 65 reviews were needed for each case in which clinical care was altered.

The investigators acknowledge that the results may differ if similar systems are implemented at other institutions or in settings having financial incentives.

"Physician-recorded medical exceptions were correct most of the time," they conclude. "Peer review of medical exceptions can identify myths and misconceptions, but the process needs to be more efficient to be sustainable."

Ann Intern Med. 2010;152:225-231.