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EDITORIALS

Outcomes and PORTs

From the catwalks of heaitiicare fashion, outcomesresearch emerges as the star of the show. While thebenefits of clinical activity have motivated doctors forgenerations, the new imperative is to combine thesewith the consumerist agenda-in effect, to putprofessional standards into consumer values.

According to the medical ethic, consent is central tomedical intervention; the consumer movement

extends this debate by introducing the concepts ofautonomy and choice. Williamson! has described the

taxonomy of this new fashion, arguing that

professional expectations must be made synergisticwith consumer interests. Isaiah Berlin2 put the agendasuccinctly: "I wish my life and decisions to dependupon myself... I wish to be a subject, not an object".Health outcomes, and pari passu a questioning of

many traditional medical practices, are high on themenu of researchers in Europe and the USA.3 In theUK, the Department of Health has responded bysetting up a clinical outcomes group, to include boththe Chief Medical Officer and the Chief NursingOfficer, and medical care research is the territory ofProf Michael Peckham, the Director of Research andDevelopment.4 Peckham’s initiative has alreadyuncovered much activity in a multiplicity of healthservice and academic institutions. Investigations byDr Robin Dowie for the Department of Health showthe considerable lack of cohesion and degree ofoverlap-there is locally funded National HealthService research, there are numerous regionally andthen centrally funded initiatives, and there is workfunded by charitable trusts, but there is virtually nostrategic coordination. One of the tasks of the healthservice research and development programme is to fillthis void. A clearing house of health outcomes haslately been established at the Nuffield Institute inLeeds.

In response to an escalation of the Medicare andMedicaid budgets and a more strident consumeristlobby, the Federal Government in the USA hasadopted a more active stance. The Department ofHealth Agency for Health Care Policy and Researchcreated a Center for Medical Effectiveness Research,which has spawned the Patient Outcomes Research

Team-PORTs-Program. Their primary questionis "what treatment works best?". Subsidiary questionsare "has the patient improved?"; "by how much?";"at what cost?"; "to whom?"; and "from whoseviewpoint?". This last question is central to both theUS and the UK initiatives.A conference in London last month trawled this

shoal of outcomes research. As was highlighted by DrIra Raskin, Deputy Director of the US programme,and by Professor Peckham, variations inrecommended practice can make a big difference topatient outcomes. Moreover, patient values and

preferences are not always incorporated into clinicaldecision-making; they need to be if the patient is to beparamount.The US approach is to address the costliest and

commonest clinical items first-big ticket items.PORTs are multidisciplinary teams led byoutstanding and acclaimed researchers in keyacademic institutions; both academic and practisingcommunity-based physicians are included. The

programme is decentralised throughout the USA butcoordinated centrally. PORTs will examine all

approaches to care, including alternative therapies.They have a four-strand activity: (a) careful review ofpublished work, including meta-analysis; (b) analysisand interpretation of practice variation; (c)dissemination of their findings and recommendations;and (d) evaluation of their effectiveness. The

programme is charged by law to produce clinicalguidelines, which are intended to put the messageacross to clinicians in a neat and easily digestiblemanner. There are numerous examples of goodclinical practice that are not widely adopted simplybecause busy doctors do not have the time, the skill, orthe will to examine the reported research.The PORTs programme has a starting budget of

$40 million. Some of its big ticket items for initialattack include prostatic hypertrophy (Wennberg,Dartmouth, Mass), back pain (Deyon, Seattle), andmyocardial infarction (Steinberg, Johns Hopkins),followed by cataracts, hip replacements, knee

replacements, biliary disease, diabetes, caesarean

sections, prevention and management of transientischaemic attacks, and schizophrenia. More or less thesame hierarchy for debate prevails in the UK. PORTsare five-year programmes that are often cemented byhope rather than expectation.The PORTs initiative is ambitious in undertaking

the research and issuing guidelines simultaneously inareas beset with doubts and ambiguities. Of one thingwe can be sure: unless we listen to the customers we

may find ourselves setting the wrong priorities.

1. Williamson C. Whose standards? Consumer and professional standardsin health care. Buckingham: Open University Press, 1992.

2. Berlin I. Four essays on liberty. London: Oxford University Press, 1969.3. Giraud A. Evaluation Médicale des Soins Hopitaliers. Paris: Ed

Economica, 1992.4. Peckham M. Research and development for the National Health Service.

Lancet 1991; 338: 367-71.