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‘Payment by results or payment by outcome? The history of measuring medicine’1 was a fascinating read. Outcome assessment is, indeed, an essential aspect in modern day National Health Service; just as in other service sectors, be it education, information technology, finance, etc. However, we wonder if healthcare outcomes are always easily measurable, and if so, also adequately measurable in the current pace of modern medicine? Though the author suggests the development of integrated care pathway (that encompasses the development and implementation of evidence-based guidelines), as a method of assessment, a major draw back is the fact that evidence is changing faster than the emergence of guidelines.
For instance, in cardiology, one of the most evidence-based specialties in medicine, current best practice is often far ahead of guidance. For example, in the recently published guidelines on prevention of cardiovascular disease in clinical practice (JBS-2),2 the AB/CD algorithm for hypertension is cited. The AB/CD algorithm will be revised soon, into A/CD, given the recent evidence on beta-blockers not being the ideal first-line agents for treatment of essential hypertension, except in the presence of heart disease.3,4 The revised joint NICE and BHS guidelines in this direction are imminent. What is even more interesting is the recently published (January 2006) NICE guidelines on statins for the primary prevention of CVD in adults.5 Evidence for statins in similar settings was available since the late 1990s.6 Furthermore, though the guidelines advocate the use of statins in adults based on cardiovascular disease risk assessment,5 the NICE guidelines on cardiovascular disease risk assessment are currently in development and are not expected until 2007. Thus, when guidelines lag behind evidence, achieving adequate measurable clinical indicators of outcome to improve quality of care is at best a utopian dream.
Competing interests Both authors are practising hospital doctors.