AOJ Vol. 49 p. 47

American Orthoptic Journal Abstract

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Volume 49, 1999, p. 49-62

Richard G. Scobee Memorial Lecture
Redefining Outcomes: Fifty Years of Decision Making in Strabismus Management
Carol F. Dickey, C.O., M.B.A.

INTRODUCTION
More than fifty years ago, in the Preface to the first edition of his book, Dr. Scobee likened anomalies of the "oculorotary muscles" to a good detective story.' He said, "the detective usually draws a map of the scene of the crime; the muscle sleuth will do well to map carefully the oculorotary muscles and their anatomic relations.... The clever detective will strive to learn why people behave as they do under certain conditions; the successful muscle sleuth will know as much as he can about the varying innervations of the oculorotory muscles in varying circumstances." As second and third generation Scobee pupils, we are the metaphorical detectives, drawing a map of the scene of the crime. Some of our tools may be more sophisticated but the process is timehonored.

Regarding his approach to strabismus management, Scobee wrote, "we should not be hesitant to employ surgery when it is indicated.... Practically all operations devised for the oculorotary muscles are slight variations of a basic few, and it is up to the individual surgeon to select the particular variation which suits him best in the light of his technique and experience. Until recently, this too was a timehonored practice.

Over the last decade, as Managed Care has come to dominate the market, a restrictive addendum has been imposed on surgical decision making. After a surgeon has selected the procedure, which based on her medical expertise and experience is most suited to a given patient, she must then solicit the approval of the patient's insurer. Whether or not a procedure is approved depends upon numerous criteria including outcomes (i.e., clinical endpoints, health-related quality of life and satisfaction with care). Critics of the approval process argue that it takes patient care decisions away from medical providers and transfers them into the hands of policy makers and administrators who are not qualified to make medical decisions. The ultimate consequence of such a practice could be a diminished standard of care. This debate is complex and it will undoubtedly continue long into the future; nonetheless, it raises certain fundamental questions about the strength of empirical clinical decisions.

Traditionally, management decisions are a function of formal training, experience and common sense. The decision maker reflects on alternatives, modifies judgements on the basis of accumulated evidence, balances risks of various kinds, considers potential consequences and synthesizes all of this to form a treatment plan that will be best for the patient under concern. All clinical and surgical decisions, however, are made under conditions of uncertainty. There are always events, beyond the control of the caregiver, that may affect the patient's outcome. Controlling for this uncertainty is one means by which policy makers, outcomes researchers and Managed Care organizations determine which procedures they will approve.

Outcomes research is a relatively new and rapidly growing science which attempts to link either structure or process or both to the outcomes of medical care. Outcomes are defined as the "consequences to the health and welfare of individuals and of society." It is not practical or necessary for every medical provider to conduct sophisticated outcomes studies or a complex analysis for every clinical choice. However, it may be useful to review some of the most common medical and surgical choices to determine if there are important differences between and among treatments that would make one more valued in the eyes of the patient.

American Orthoptic Journal Abstract