Clinical Practice Guidelines: the More, the Better?
Keywords:
Guidelines, trustworthy, limitation, biasAbstract
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.
References
2. Sox H, McNeil B, Eden J, Wheatley B. Knowing What Works in Health Care: A Roadmap for the Nation. National Academies Press; 2008.
3. McAlister FA, Van Diepen S, Padwal RS, Johnson JA, Majumdar SR. How evidence-based are the recommendations in evidence-based guidelines? PLoS Med. 2007;4:e250.
4. Shaneyfelt TM, Centor RM. Reassessment of clinical practice guidelines: go gently into that good night. JAMA. 2009;301:868-869.
5. Sniderman AD, Furberg CD. Why guideline-making requires reform. JAMA. 2009;301:429-431.
6. Leavitt S. Misguided pain guidelines? When strong claims follow from weak evidence. Pain Treat Top. 2009;4:1-8.
7. Reames BN, Krell RW, Ponto SN, Wong SL. Critical evaluation of oncology clinical practice guidelines. J Clin Oncol. 2013;31:2563-2568.
8. Kung J, Miller RR, Mackowiak PA. Failure of clinical practice guidelines to meet institute of medicine standards: two more decades of little, if any, progress. Arch Intern Med. 2012;172:1628-1633.
9. Choudhry NK, Stelfox HT, Detsky AS. Relationships between authors of clinical practice guidelines and the pharmaceutical industry. JAMA. 2002;287:612-617.
10. Young BK, Greenberg PB. Are the Institute of Medicine’s Trustworthiness Guidelines Trustworthy? RI Med J. 2013;96:13-14.
11. Ransohoff DF, Pignone M, Sox HC. How to decide whether a clinical practice guideline is trustworthy. JAMA. 2013;309:139-140.
12. Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA. 2005;294:716-724.
13. Tinetti ME, Fried T. The end of the disease era. Am J Med. 2004;116:179-185.
14. Anderson G. Chronic Conditions: Making the Case for Ongoing Care. Johns Hopkins University; 2004.
15. Shaneyfelt TM, Mayo-Smith MF, Rothwangl J. Are guidelines following guidelines?: The methodological quality of clinical practice guidelines in the peer-reviewed medical literature. JAMA. 1999;281:1900-1905.
16. Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. Potential benefits, limitations, and harms of clinical guidelines. BMJ. 1999;318:527-530.
17. Mitka M. Groups Aim for Trustworthy Clinical Practice Guidelines. JAMA. 2014;311:1187-1188.
18. Hyams AL, Shapiro DW, Brennan TA. Medical practice guidelines in malpractice litigation: an early retrospective. J Health Polit Policy Law. 1996;21:289-313.
19. Samanta A, Mello MM, Foster C, Tingle J, Samanta J. The role of clinical guidelines in medical negligence litigation: a shift from the Bolam standard? Med Law Rev. 2006;14:321-366.
20. Cosgrove L, Bursztajn HJ, Erlich DR, Wheeler EE, Shaughnessy AF. Conflicts of interest and the quality of recommendations in clinical guidelines. J Eval Clin Pract. 2013;19:674-681.
21. Talwalkar JA. Improving the transparency and trustworthiness of subspecialty-based clinical practice guidelines. In: Mayo Clinic Proceedings. Vol 89. Elsevier; 2014:5-7.
22. Lenzer J. Why we can’t trust clinical guidelines. BMJ. 2013;346.
23. Walter LC, Davidowitz NP, Heineken PA, Covinsky KE. Pitfalls of converting practice guidelines into quality measures: lessons learned from a VA performance measure. JAMA. 2004;291:2466-2470.
