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

Abstract

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