Article

Reassessment of clinical practice guidelines: go gently into that good night.

JAMA The Journal of the American Medical Association (Impact Factor: 30.39). 03/2009; 301(8):868-9. DOI: 10.1001/jama.2009.225
Source: PubMed
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    ABSTRACT: Clinical practice guidelines are supposed to be evidence based and unbiased. High quality guidelines have the potential to promote the use of effective clinical services, minimize undesirable practice variation, and reduce the use of unnecessary services. Unfortunately, most of the guidelines produced thus far are flawed and untrustworthy. High quality guidelines may still have the intrinsic limitation of being too disease-focused rather than patient-focused, and lack applicability and validity when dealing with patients with multiple comorbidities or diseases. When applicable, clinical practice guidelines may serve as a relative guidance, rather than the absolute standard. Physicians need to be critical and vigilant when faced with a plethora of guidelines as following flawed practice guidelines may result in harm to patients. The use of clinical practice guidelines as the “standard of care” as well as for pay-for-performance based on guideline adherence is unjustified.
    North American journal of medicine & science 05/2015; 2015(8).
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    [Show abstract] [Hide abstract]
    ABSTRACT: Clinical practice guidelines are supposed to be evidence based and unbiased. High quality guidelines have the potential to promote the use of effective clinical services, minimize undesirable practice variation, and reduce the use of unnecessary services. Unfortunately, most of the guidelines produced thus far are flawed and untrustworthy. High quality guidelines may still have the intrinsic limitation of being too disease-focused rather than patient-focused, and lack applicability and validity when dealing with patients with multiple comorbidities or diseases. When applicable, clinical practice guidelines may serve as a relative guidance, rather than the absolute standard. Physicians need to be critical and vigilant when faced with a plethora of guidelines as following flawed practice guidelines may result in harm to patients. The use of clinical practice guidelines as the “standard of care” as well as for pay-for-performance based on guideline adherence is unjustified.
    North American journal of medicine & science 05/2015; 2015 (8)(2).
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    ABSTRACT: Clinical guidelines were initially written as physician education tools for application within individual idealized patient encounters. Though based on large studies, applying guidelines to populations was not originally intended. However, this notion has been naively adopted in the rush to generalize, measure, and regulate quality [1]. Since given the new definition by the Institute of Medicine (IOM) in 1990, clinical guidelines have increasingly become a familiar part of clinical practice. As currently defined by IOM, clinical guidelines are " systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. " [2]. Guidelines are widely considered evidence based, unbiased, and valid. High quality guidelines have the potential to promote the use of effective clinical services, minimize undesirable practice variation, and reduce the use of unnecessary services [3]. Unfortunately, current use of the term " guidelines " has strayed away from the original intent of the IOM. Most so called " guidelines " publications are actually expert consensus reports [4]. There have been many concerns expressed, including limitations in the scientific evidence on which the guidelines relied, a lack of transparency of the guideline development groups' methodologies, and conflict of interest among guideline development group members and funders, as well as questions regarding how to reconcile conflicting guidelines [5]. Very often, we see bias in the development of guidelines , involving the reviewed research, misrepresentation of the data, or failure to assess the quality of the evidence supporting the recommendations. Inadequate or weak evidence may lead to conclusions based on value judgments, organizational preferences, or opinion. Specialty and subspecialty societies can use guidelines to enlarge their area of expertise in a competitive medical field. Federal guideline agencies usually focus on cost saving approaches, while committees influenced by industry are more likely to shape recommendations to accord with industry needs [6]. Also, the validity of systematic reviews and meta-analyses may also be negatively affected by bias. For example, several practice guidelines on long-term opioid therapy for chronic pain were published between 2008 and 2011. Although each guideline was based on analysis of essentially the same body of published research, the guideline conclusions differed significantly [6]. It reached the point that any group of individuals could designate itself a guideline group to come up with guidelines on some disease/condition; and different guideline groups could review the same disease/condition and reach different conclusions [7].