An analysis of 25 Milliman & Robertson guidelines for surgery: data-driven versus consensus-derived clinical practice guidelines

Abstract

Summary background data: Managed care guidelines such as those by Milliman & Robertson (M&R) are being implemented with increasing frequency. Many fellows of the American College of Surgeons have raised concerns that the targets set by the M&R guidelines are too aggressive. Uninformed attempts to reach these targets may harm patients. The primary hypothesis of this study was that many of the M&R guidelines are at wide variance from the actual length of stay of patients treated for these diseases.

Methods: Data for the determination of the present practice of care for patients in 25 M&R guidelines were obtained from the hospital discharge data base for North Carolina for 1996. Twenty-five of the M&R guidelines were compared to the actual patient mean, mode, and median length of stay.

Results: In 8 of the 25 patient groups, the difference between the actual mean length of stay and M&R guidelines exceeded 5 days.

Conclusions: Many of the M&R guidelines were found to be at wide variance from the actual length of stay of patients treated for these diseases in North Carolina. For many patients, the M&R guidelines are not applicable. Applying them in an uninformed way--in other words, discharging patients from the hospital too early--may hurt some patients. This study should not be interpreted as a criticism of the trend to use guidelines in general; rather, it should be considered a cautionary note that all guidelines must be reviewed scientifically to determine their soundness, applicability, and credibility.