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March 13, 1991

Unwanted Variations in the Rules of Practice

JAMA. 1991;265(10):1306-1307. doi:10.1001/jama.1991.03460100108036

Consensus, as Webster reminds us, signifies "general agreement or unanimity; group solidarity in sentiment and belief."1 The article by Kellie and Kelly in this issue of The Journal2 confirms, once again, that there is little general agreement in medicine, and group solidarity about the standards of practice seems localized to geographic area and medical specialty. The authors demonstrate wide variations across the nation in the rules that professional review organizations (PROs) have adopted for evaluating whether physicians should be allowed to undertake a carotid endarterectomy, remove a cataract, or implant a pacemaker. The PRO guidelines often depart substantially from nationally developed practice guidelines.

The work by Kellie and Kelly carries an important message. The strategies of micromanaged care have led to the development of a plethora of rules to govern clinical practice. Some, as in the case of the PRO, are at least accessible to analysis. Many others,