Practice guidelines and standards: an overview

Research trends in evidence-based medicine: a joinpoint regression analysis of more than 50 years of publication data

Background

Evidence-based medicine (EBM) has developed as the dominant paradigm of assessment of evidence that is used in clinical practice. Since its development, EBM has been applied to integrate the best available research into diagnosis and treatment with the purpose of improving patient care. In the EBM era, a hierarchy of evidence has been proposed, including various types of research methods, such as meta-analysis (MA), systematic review (SRV), randomized controlled trial (RCT), case report (CR), practice guideline (PGL), and so on. Although there are numerous studies examining the impact and importance of specific cases of EBM in clinical practice, there is a lack of research quantitatively measuring publication trends in the growth and development of EBM. Therefore, a bibliometric analysis was constructed to determine the scientific productivity of EBM research over decades.

Methods

NCBI PubMed database was used to search, retrieve and classify publications according to research method and year of publication. Joinpoint regression analysis was undertaken to analyze trends in research productivity and the prevalence of individual research methods.

Findings

Analysis indicates that MA and SRV, which are classified as the highest ranking of evidence in the EBM, accounted for a relatively small but auspicious number of publications. For most research methods, the annual percent change (APC) indicates a consistent increase in publication frequency. MA, SRV and RCT show the highest rate of publication growth in the past twenty years. Only controlled clinical trials (CCT) shows a non-significant reduction in publications over the past ten years.

Conclusions

Higher quality research methods, such as MA, SRV and RCT, are showing continuous publication growth, which suggests an acknowledgement of the value of these methods. This study provides the first quantitative assessment of research method publication trends in EBM.

Maintaining Vigilance to Promote Best Outcomes for Hospitalized Elders

This article presents contemporary evidence regarding the promotion of a culture of caring for hospitalized older persons through nursing vigilance. A summary of the literature regarding the need for vigilance, what to be vigilant about, and how vigilance can be enhanced for hospitalized older persons is provided, as well as recommendations for practice, education, research, and policy. Evidence indicates that vigilance is enhanced by having nurses who have specialized knowledge to differentiate normal aging from abnormal pathology, and who use point-of-care information, electronic health records, patient care information systems, and computerized adverse events detection systems to monitor symptoms and outcomes and prevent errors. The use of specialized models of patient care and adequate nurse-patient staffing also have been shown to prevent errors and improve patient outcomes.

Alternative-site anesthesia: guidelines affecting clinical care

The delivery of anesthesia care to patients in alternative sites outside the operating room is a rapidly growing area of clinical activity. We have reviewed our patient care guidelines and standards developed for the operating room and applied them to sites as varied as a magnetic resonance imaging center in radiology to a plastic surgery office. Now specific societies and guidelines are being developed for alternative site practice.

Quality care and practice variation: the roles of practice guidelines and public profiles

Goals of the quality-of-care initiative are to improve the structure, process, and outcome of health care. The effectiveness of methods to improve quality have been largely unverified. Most methods are costly to implement and time-consuming to perform; some threaten professional autonomy. The characteristic feature of modern medicine that fuels the debate over quality is the variation in the delivery of health care. This review examines the "variation phenomenon" in medicine and the roles that practice guidelines and physician profiling have in improving health care, in general, and for adult cataract, in particular.

Practice guidelines: the radiology perspective

Clinical practice guidelines have emerged as a reality for medical practitioners over the past 20 years. Although virtually all groups interested in the development of practice guidelines hope for improvements in patient care, secondary expectations vary widely among those using them. Their use in daily practice by physicians has met with resistance from barriers including concerns of "cookbook" medicine, a loss of autonomy, and increased professional liability. The recent experience of the ACR in addressing these challenges illustrates that physicians are receptive to steps perceived to mitigate the risks accompanying the use of guidelines as well as to efforts to increase their understanding of implementing guidelines in clinical practice. The experiences of other medical societies and an inventory of future trends reveal additional challenges associated with the use of practice guidelines, as third parties look to guidelines as points of reference for gauging the performance of health care providers.

Evidence-based practice in Hong Kong: issues and implications in its establishment

Evidence-based practice has been widely discussed in the literature, but it is not common or well adopted in nursing practice, both in Hong Kong and other countries. This article aims to examine the relationships between three important elements of evidence-based practice: systematic reviews, clinical guidelines and protocols. Current issues associated with evidence-based practice in Hong Kong are explored. Specific suggestions are given to researchers, practitioners, managers and academics so that the current situation can be advanced.

The pharmacologic management of childhood asthma

Asthma treatment is based on the appropriate recognition and classification of children warranting treatment. Adequate treatment requires that children and parents have a good understanding of the disease and expectations for good control. Assessment requires a thorough history of symptoms, impairments of physical activity, past history of exacerbations, and understanding of triggering events. Therapy then must be appropriately implemented to reverse the symptoms and prevent future exacerbations. The approach in pediatrics is to be conservative, to use the safe and proven therapy, and to prevent the potential morbidity of the disease. These goals provide the rationale in childhood immunization. The literature suggests that the appropriate and conservative approach for children with persistent asthma, of any disease severity, is the use of low-dose inhaled corticosteroids that may be combined with an inhaled long-acting bronchodilator. This therapy is the most effective in reducing symptoms and exacerbations and preventing the potential mortality from the disease. It also allows children to be able to enjoy physical activity with their friends. Expectations should be high. Concerns about the potential for adverse effects should always be addressed proactively and should be balanced with the potential of adverse events from the disease.

Mediating the cultural boundaries between medicine, nursing and management--the central challenge in hospital reform

This paper documents the resilience of medical and nursing profession-based subcultures and the extent of the differences between them. Against this background, we assess the capacity and willingness of medical and nursing managers to promote changes that will extend the accountability of clinicians and engender more evidence-based, financially driven and output-oriented approaches to service delivery.

Evaluating the implications of clinical practice guidelines for patient care

Patient care evaluation studies have been developed by the Commission on Cancer of the American College of Surgeons. The studies were primarily designed to monitor trends in diagnosis, therapy, and outcome of specific oncologic diseases in hospitals and cancer centers. As they reflect the current standards of patient care, patient care evaluation studies have become valid tools of quality management in medicine. In an international pilot project that began in 1996, this approach was redefined to evaluate the impact of current clinical practice guidelines in oncology. Close cooperation between medical societies in the United States and Germany under the coordination of the Commission on Cancer and the Institute of Medical Informatics at the Justus-Liebig-University of Giessen was established. This infrastructure for data collection, data management, analysis, and interpretation of results allows for the recognition of international differences in patient care. Our results indicate discrepancies between current state-of-the-art patient care represented by clinical practice guidelines and the diagnostic and therapeutic procedures in the clinical routine. Patient care evaluation studies are designed as exploratory, not confirmatory, trials. In contrast with confirmatory trials, their aims may not always lead to predefined hypotheses. They reflect routine practice and are not the basis of the formal proof of efficacy, although they may contribute to the total body of relevant evidence. Without this comprehensive approach to evaluation, the potential of clinical practice guidelines to improve patient care remains unknown.

Reconsidering clinical accountability. An examination of some dilemmas inherent in efforts to bolster clinician accountability

The paper critically appraises current efforts to bolster the accountability of clinicians. The paper opens with an examination of the values, meaning and rules which underpin different accountability systems. Against this background we canvass conceptual, practical and ethical issues which need to be addressed if efforts to extend the accountability of clinicians are to meet with success.

Controlled trials of CQI and academic detailing to implement a clinical practice guideline for depression

BACKGROUND

The release of the Agency for Health Care Policy and Research (AHCPR)'s Guideline for the Detection and Treatment of Depression in Primary Care created an opportunity to evaluate under naturalistic conditions the effectiveness of two clinical practice guideline implementation methods: continuous quality improvement (CQI) and academic detailing. A study conducted in 1993-1994 at Kaiser Permanente Northwest Division, a large, not-for-profit prepaid group practice (group-model) HMO, tested the hypotheses that each method would increase the number of members receiving depression treatment and would relieve depressive symptoms.

METHODS

Two trials were conducted simultaneously among adult primary care physicians, physician assistants, and nurse practitioners, using the same guideline document, measurement methods, and one-year follow-up period. The academic detailing trial was randomized at the clinician level. CQI was assigned to one of the setting's two geographic areas. To account for intraclinician correlation, both trials were evaluated using generalized equations analysis.

RESULTS

Most of the CQI team's recommendations were not implemented. Academic detailing increased treatment rates, but--in a cohort of patients with probable chronic depressive disorder--it failed to improve symptoms and reduced measures of overall functional status.

CONCLUSIONS

New organizational structures may be necessary before CQI teams and academic detailing can substantially change complex processes such as the primary care of depression. New research and treatment guidelines are needed to improve the management of persons with chronic or recurring major depressive disorder.

Pediatric practice guidelines: implications for nurse practitioners

Practice guidelines are promoted as an important means of achieving high-quality, cost-effective health care. Nurse practitioners must understand what practice guidelines are and how they are developed and be willing to put them into practice. This discussion begins with a description of practice guidelines specific to pediatrics. The terminology used in reference to these "clinical tools" are differentiated and their historic and contemporary influences are summarized. The complexity of guideline development and attributes of a quality practice guideline are described. Finally, the pivotal roles nurse practitioners can play in putting guidelines into practice are suggested.

Assessing the predictive validity of the RAND/UCLA appropriateness method criteria for performing carotid endarterectomy

We assessed the predictive validity of an expert panel's ratings of the appropriateness of carotid endarterectomy by comparing ratings to the results of subsequent randomized clinical trials. We found the trials confirmed the ratings for 44 indications (covering almost 30% of operations performed in 1981) and refuted the ratings for none.

Attributes of clinical guidelines that influence use of guidelines in general practice: observational study

OBJECTIVE

To determine which attributes of clinical practice guidelines influence the use of guidelines in decision making in clinical practice.

DESIGN

Observational study relating the use of 47 different recommendations from 10 national clinical guidelines to 12 different attributes of clinical guidelines-for example, evidence based, controversial, concrete.

SETTING

General practice in the Netherlands.

SUBJECTS

61 general practitioners who made 12 880 decisions in their contacts with patients.

MAIN OUTCOME MEASURES

Compliance of decisions with clinical guidelines according to the attribute of the guideline.

RESULTS

Recommendations were followed in, on average, 61% (7915/12 880) of the decisions. Controversial recommendations were followed in 35% (886/2497) of decisions and non-controversial recommendations in 68% (7029/10 383) of decisions. Vague and non-specific recommendations were followed in 36% (826/2280) of decisions and clear recommendations in 67% (7089/10 600) of decisions. Recommendations that demanded a change in existing practice routines were followed in 44% (1278/2912) of decisions and those that did not in 67% (6637/9968) of decisions. Evidence based recommendations were used more than recommendations for practice that were not based on research evidence (71% (2745/3841) v 57% (5170/9039)).

CONCLUSIONS

People and organisations setting evidence based clinical practice guidelines should take into account some of the other important attributes of effective recommendations for clinical practice.

Online practice guidelines: issues, obstacles, and future prospects

The "guidelines movement" was formed to reduce variability in practice, control costs, and improve patient care outcomes. Yet the overall impact on practice and outcomes has been disappointing. Evidence demonstrates that the most effective method of stimulating awareness of and compliance with best practices is computer-generated reminders provided at the point of care. This paper reviews five steps along the path from the development of a guideline to its integration into practice and the subsequent evaluation of its impact on practice and outcomes. Issues arising at each step and obstacles to moving from one step to the next are described. Last, developments that could help overcome the obstacles are highlighted. These include 1) more rapid knowledge acquisition using data mining, 2) better accommodation to imprecise knowledge in clinical algorithms using fuzzy logic, 3) development of a shareable model for guideline representation and execution, and 4) more widespread availability of clinically robust information systems that support decision-making at the point of care.

Differences in generalist and specialist physicians' knowledge and use of angiotensin-converting enzyme inhibitors for congestive heart failure

OBJECTIVE

To quantify the extent and determinants of underutilization of angiotensin-converting enzyme (ACE) inhibitors for patients with congestive heart failure, especially with respect to physician specialty and clinical indication.

DESIGN

Survey of a national systematic sample of physicians.

PARTICIPANTS

Five hundred family practitioners, 500 general internists, and 500 cardiologists.

MEASUREMENTS AND MAIN RESULTS

Physicians' choice of medications were determined for four hypothetical patients with left ventricular systolic dysfunction: (1) new-onset, symptomatic; (2) asymptomatic; (3) chronic heart failure, on digitalis and diuretic; and (4) asymptomatic, post-myocardial infarction. For each patient, randomized controlled trials have demonstrated that ACE inhibitors decrease mortality or the progression of symptoms. Among the 727 eligible physicians returning surveys (adjusted response rate 58%), approximately 90% used ACE inhibitors for patients with chronic heart failure who were already taking digitalis and a diuretic. However, family practitioners and general internists chose ACE inhibitors less frequently (p < or = .01) than cardiologists for the other indications. Respective rates of ACE inhibitor use for each simulated patient were new-onset, symptomatic (family practitioners 72%, general internists 76%, cardiologists 86%); asymptomatic (family practitioners 68%, general internists 78%, cardiologists 93%): and asymptomatic, postmyocardial infarction (family practitioners 58%, general internists 70%, cardiologists 94%). Compared with generalists, cardiologists were more likely [p < or = .05] to increase ACE inhibitors to a target dosage (45% vs 26%) and to tolerate systolic blood pressures of 90 mm Hg or less [43% vs 15%).

CONCLUSIONS

Compared with cardiologists, family practitioners and general internists probably underutilize ACE inhibitors, particularly among patients with decreased ejection fraction who are either asymptomatic or post-myocardial infarction. Educational efforts should focus on these indications and emphasise the dosages demonstrated to lower mortality and morbidity in the trials.

Automated pharmacy databases and behavioral health care quality assurance

Randomized, double-blind, placebo-controlled trials suggest that medications can be efficacious in several psychiatric disorders. The effectiveness of medications as they are used in practice remains to be seen. Automated pharmacy data give evaluation researchers tools to examine the quality of care for people using psychotropic medications. Reasonably convincing data indicates that automated pharmacy records are valid measures of medication consumption. Evaluation research is needed in areas such as standard setting, risk adjustment, and the linking of pharmacy data to outcome measures.

Performance measurement in prostate cancer care: beyond report cards

OBJECTIVES

Review and analyze various approaches to performance measurement in health care, demonstrating the value of provider-initiated performance measurement in which ongoing monitoring of both processes and outcomes of care coupled with the use of clinical guidelines enhances performance improvement efforts. Describe some of the issues and findings associated with the use of such a methodology in prostate cancer care.

METHODS

Literature review and case study.

RESULTS

There are a number of significant limitations in the use of a "report card" methodology to improve quality and efficiency in health care. The complementary approach of combining "instrument panels" and clinical guidelines within an overall continuous quality improvement framework appears to have resulted in improved clinical outcomes and reduced costs in a six-physician urology group located in a heavily managed-care penetrated market.

CONCLUSIONS

Performance measurement tools are integral to efforts to improve outcomes and efficiency in health care. Providers of care might consider adapting the kind of performance improvement methodology described in this article. Practice benefits including improved clinical and economic outcomes are likely to follow.

An expert system for performance-based direct delivery of published clinical evidence

OBJECTIVE

To develop a system for clinical performance improvement through rule-based analysis of medical practice patterns and individualized distribution of published scientific evidence.

METHODS

The Quality Feedback Expert System (QFES) was developed by applying a Level-5 expert system shell to generate clinical direct reports for performance improvement. The system comprises three data and knowledge bases: 1) a knowledge base of measurable clinical practice parameters; 2) a practice pattern database of provider-specific numbers of patients and clinical activities; and 3) a management rule base comprising "redline rules" that identify providers whose practice styles vary significantly. Clinical direct reports consist of a table of practice data highlighting individual utilization vs recommendation and selected pertinent statements from medical literature.

RESULTS

The QFES supports integration of recommendations from several guidelines into a comprehensive and measurable quality improvement plan, analysis of actual practice patterns and comparison with accepted recommendations, and generation of a confidential individualized direct report to those who significantly deviate from clinical recommendations. The feasibility of the practice pattern analysis by the QFES was demonstrated in a sample of 182 urinary tract infection cases from a primary care clinic. In a set of clinical activities, four questions/procedures were associated with significant (p < 0.001) and unexplained variation.

CONCLUSION

The QFES provides a flexible tool for the implementation of clinical practice guidelines in diverse and changing clinical areas without the need for special program development. Preliminary studies indicate utility in the analysis of clinical practice variation and deviations. Using data obtained through a retrospective chart audit, the QFES was able to detect overutilization, and to identify nonrandom differences in practice patterns.

Practice guidelines in the addictions. Recent developments

Consensually established principles of clinical conduct, known variously as practice guidelines, standards, protocols, or algorithms, have proliferated throughout medicine over the past decade. Institutional and disciplinary efforts to develop and promulgate guidelines for the treatment of additive disorders have recently been initiated. We review guideline development activities of the American Psychiatric Association, American Psychological Association, American Society of Addiction Medicine, American Nurses Association, National Association of Social Workers, and Center for Substance Abuse Treatment of the Substance Abuse and Mental Health Services Administration. Medical care performance and outcome assessments are discussed with attention to the role they can play in evaluating and refining guidelines. Potential effects of guidelines, salutary and deleterious, on clinical practice in the addictions are delineated.

Informatics: essential infrastructure for quality assessment and improvement in nursing

In recent decades there have been major advances in the creation and implementation of information technologies and in the development of measures of health care quality. The premise of this article is that informatics provides essential infrastructure for quality assessment and improvement in nursing. In this context, the term quality assessment and improvement comprises both short-term processes such as continuous quality improvement (CQI) and long-term outcomes management. This premise is supported by 1) presentation of a historical perspective on quality assessment and improvement; 2) delineation of the types of data required for quality assessment and improvement; and 3) description of the current and potential uses of information technology in the acquisition, storage, transformation, and presentation of quality data, information, and knowledge.

The standard of care

The professional standard of care has historically been defined in terms of the practice of reasonable, prudent physicians. In court, physicians are needed in most cases to testify as to what is the standard of practice and to verify the relevance of published materials that may be presented as being descriptive of the standard of care. Proposed standards have been published by many organizations and institutions. The medical literature also serves as a source of information concerning medical practices. Court cases may be decided in a way that suggests that the usual practices of physicians are inadequate.

Compliance with practice guidelines: clinical autonomy revisited

The development of practice guidelines is gaining popularity in both North America and Europe. This review article explores the different reasons behind guideline development, the methodologies used and the effects assessed so far. Experience since 1982 with a guideline development programme at CBO is discussed in more detail. The consequences guidelines have for professional autonomy are discussed, and it is concluded that guidelines can enforce professionalization as well as accountability and efficiency when developed within the framework of a consistent goal-method-effect scheme and applied as an integral part of professional quality assurance activities.

Quality assurance in health care. From a traditional towards a modern approach

This review article is about some recent developments in quality assurance in health care. A traditional and a modern approach are distinguished. The traditional approach is marked by a medical perspective and quality is defined as a property of medical care. Development of standards and criteria and inspection of conformance to them is the guiding principle for traditional medical quality assurance. The modern approach is marked by a strong influence of industrial principles on medical quality assurance. Industrial principles provide a new theory upon which medical quality assurance can be based. Aspects of care which are associated with the perceived quality are identified and are legitimate objects of medical quality assurance. The guiding principle is to influence experiences of (internal or external) customers by modelling the care according to clarified expectations. The university hospital of Maastricht provides an example of how modern principles of quality assurance are put into practice.

Nutrition screening and assessment: current practices and dietitians' leadership roles

OBJECTIVE

To ascertain hospital nutrition screening and assessment practices and the need for additional resources to facilitate these processes.

DESIGN

A survey questionnaire was developed to ascertain screening protocols, assessment procedures and tools, relevant training and research needs, and respondent characteristics.

SAMPLE

The survey was sent to 988 members of Dietitians in Nutrition Support, a dietetic practice group of The American Dietetic Association; 388 (39.3%) responses were used for analysis.

STATISTICAL ANALYSIS

Descriptive statistics were used to calculate response frequency. chi 2 Statistics were used to test associations between nutrition assessment practices and association membership, nutrition support team activity, patient load, time allocations, and type and size of hospital.

RESULTS

Most institutions had policies for screening (90.2%); 68.7% of dietitians were involved in screening either alone or with others. Assessment practices within hospitals varied widely: 45.9% used a standard form; 66.8% assessed patients at risk; and 10.6% assessed all patients. Typical assessments included height and weight, diagnosis, weight history, albumin, food intolerance, and allergies. Social histories and sophisticated methods such as indirect calorimetry were used infrequently. Most assessments (54.5%) took 31 to 59 minutes; 35.0% of the dietitians spent more than half their time doing assessments. A large percentage (48.7%) of respondents viewed the dietitian as having greatest influence on assessment policies; others thought physicians (23.2%), administrators (15.7%), nurses (6.2%), or pharmacists (6.5%) had the greatest influence.

APPLICATIONS/CONCLUSIONS

Recommended improvements include improved standards of practice, development of written protocols and practice guidelines, better use of human resources, standardization of assessment procedures throughout the profession, and empowerment of dietitians to assume a stronger leadership role in this dimension of dietetics practice.

An audit of distribution and use of guidelines for management of head injury

Ensuring effective distribution of guidelines is an important step towards their implementation. To examine the effectiveness of dissemination of a guidelines card on management of head injury and determine its usefulness to senior house officers (SHOs), a questionnaire survey was performed in May 1990, after distribution of the cards in induction packs for new doctors and at postgraduate lectures and displaying the guidelines in accident and emergency departments and wards. A further survey, in March 1992, assessed the impact of modifying the distribution. All (175) SHOs working in general surgery, accident and emergency medicine, orthopaedics, and neurosciences on 1 February 1990 in 19 hospitals including two neurosurgical units in Northern region were sent self completion questionnaires about awareness, receipt, use, and perceived usefulness of the guidelines. 131 of 163(80%) SHOs in post responded (median response from hospitals 83% (range 50%-100%)). Over three quarters (103, 79%) of SHOs were aware of the guidelines and 82(63%) had ever possessed a guidelines card. Only 36(44%) acquired the card in the induction pack. 92%(98/107) found them useful and 81% (89/110) referred to them to some extent. Owning and carrying the card and referring to guidelines were associated with departmental encouragement to use the guidelines. Increasing the displays of guidelines in wards and departments and the supply of cards to consultants in accident and emergency medicine as a result of this survey did not increase the number of SHOs who received cards (52/83, 63%), but more (71/83, 86%) were aware of the guidelines. The guidelines were welcomed by SHOs and used in treating patients with head injury, but their distribution requires improvement. Increased use of the guidelines may be achieved by introducing other distribution methods and as a result of encouragement by senior staff.

Failure to document

The failure to adequately document events in the written clinical record is the major reason for letters of inquiry from Peer Review Organizations (PROs). The major causes of inadequate documentation are time pressures, the mind set of physicians, increasing subspecialization with the fragmentation of patient care, and a distrust of review activities in general. However, the accurate recording of medical events that ensue during the course of caring for patients is an integral aspect of the profession of medicine.

Guidelines to shape clinical practice. The role of medical societies: the Dutch experience in comparison with recent developments in the American approach

In the last few years there has been a growing interest in the development of guidelines for care. The most important aim of these guidelines is to improve the quality of care by changing the daily practice of physicians in the desired direction. Therefore besides the scientific basis of guidelines, emphasis should be placed on the implementation of guidelines. Experience in the Netherlands, where medical societies contribute significantly to the procedure of consensus guidelines development, are described in comparison with new ideas in the U.S.A. regarding criteria setting. Involvement of physician organisations to the development procedure is a necessary requirement for guidelines to shape clinical practice. Furthermore, some interventions used in The Netherlands for improving implementation of guidelines in daily practice are mentioned.

Physician recertification and outcomes assessment

Physician recertification poses a unique challenge to member boards of the American Board of Medical Specialties (ABMS) charged with the responsibility of credentialing physicians. The key issue that emerges in recertification programs is how to evaluate performance in practice. Although some test of knowledge may be appropriate, an evaluation of clinical performance has become essential in recertification programs. To meet this challenge, ABMS boards have adopted methods to evaluate performance in practice. However, regardless of the methods chosen, criteria are needed to serve as standards. This article considers the application of outcomes assessment in the definition of standards for recertification. When direct outcome assessment may not be possible, outcome-validated process measures may provide a suitable alternative.

Clinical outcomes management and disease staging

Clinical outcomes management includes multiple approaches for evaluating and improving the quality and cost effectiveness of medical care. The usefulness of outcomes assessments depends, in part, on how well the clinical issues have been specified and whether the analyses are sensitive to the diverse clinical characteristics of the patients receiving the medical care in question. Measures of severity of illness and, in particular, Disease Staging, have an important role in outcomes assessment by classifying diseases along dimensions that have prognostic significance. This article reviews current applications of Disease Staging for outcomes assessment and management.