Breaking the Chains of Clinical Practice Guidelines: Could SCAMPs Be the Answer?

I have written extensively about the challenges in driving better outcomes in our patients with advanced CKD and ESRD. Not the least of these is the continued reliance of clinicians, payers and regulators on clinical practice guidelines (CPGs) to determine what domains are worthy of focus for public reporting and for payment to dialysis facilities. Unfortunately, however, the CPGs in nephrology are small in number and, despite excellent performance across the ESRD population on overall, we have not moved the needle on the really important primary outcomes that will ultimately result in better lives for our patients: lower mortality, fewer hospitalizations and an improved experience of care.

A recent article in Health Affairs described a different approach to achieving the goals for which we all strive—the use of standardized clinical assessment and management plans (SCAMPs), “a clinician-designed approach to promoting care standardization that accommodates patients’ individual differences, respects providers’ clinical acumen, and keeps pace with the rapid growth of medical knowledge.”(1) This approach was developed and has been applied largely by pediatricians as an outgrowth of their frustration with CPGs. Nearly 50 SCAMPs have been developed, and more than 12,000 patients currently are enrolled in SCAMP programs.

Initially developed for children with serious cardiovascular disease, the SCAMPs have three explicit goals that are similar to the Triple Aim: reducing variations in practice; improving patient outcomes and optimizing resource use.(2) SCAMPs utilize the paradigm of a quality-improvement project to drive change in practice and to impact clinical outcomes. It is a living process, with iterations on a regular basis to account for experience and new scientific knowledge. The process involved is articulated on the SCAMPs website:(2)

• Establish a foundation for “sound” clinical practice on a particular disorder through a thorough literature review to compose a background position paper and, if necessary, a focused retrospective study to analyze the results of current practice
• Formulate several (generally eight to twelve) plausible outcomes, or questions that address known gaps in knowledge regarding management of the disorder, which become the focus of targeted data collection
• Arrive at expert consensus on the entry criteria, assessment recommendations, and management algorithms (decision trees) for the SCAMP
• Develop data forms and computer-based tools that facilitate the implementation of the SCAMP and the targeted collection of data on SCAMP use, deviations, and patient outcomes
• Perform periodic analysis of SCAMP data using frequency and Bayesian statistical approaches to assess the effectiveness of recommendations from both a clinical and cost-effectiveness perspective
• Revise and improve the SCAMP based on this analysis, best clinical judgment, and relevant updates from the medical literature

There are important policy implications of the use of SCAMPs,(1) including providing practical, clinically relevant areas of focus for quality oversight, public reporting and potentially pay-for-performance programs;(2) enabling providers, particularly in an integrated care environment/ACO/ESCO, to evaluate the cost-effectiveness of competing interventions;(3) and encouraging innovation in care delivery where a preponderance of evidence is present, decreasing the paralysis that comes from waiting for proof from randomized controlled trials. In nephrology, focusing on fluid management, infection control, diabetes management, medication management and end-of-life care, among other key complex clinical areas, and engaging teams of providers to develop SCAMPs in these and other areas might be just what we need to jump-start the effort to improve patients’ lives.(3,4) We owe it to our patients to understand this approach and determine if this is an important path for us to pursue as a community. I submit that it is a tool worth trying!

As Dale Carnegie said,

“Most of the important things in the world have been accomplished by people who have kept on trying when there seemed to be no hope at all.”

 References:

1. Farias M, Jenkins K, Lock J et al. Standardized Clinical Assessment and Management Plans (SCAMPs) Provide a Better Alternative to Clinical Practice Guidelines. Health Affairs 32:911–920, 2013.
2. http://www.scamps.org
3. Parker TF, Straube BM, Nissenson A et al. Dialysis at a Crossroads—Part II: A Call for Action. Clin J Am Soc Nephrol 7:1026–1032, 2012.
4. Parker TF, Hakim R, Nissenson AR et al. A Quality Initiative. Reducing Rates of Hospitalizations by Objectively Monitoring Volume Removal. Nephrol News Issues 27:34–36, 2013.