How I would reinvent guidelines


Category : Medical Rants

The title of this rant is almost disingenuous, as my main premise is that we have let guideline production “drift” and therefore my goal is return guideline development to its original intention. Our approach to guidelines reminds me of my favorite Led Zeppelin song – “Dazed and Confused.” I hope that a thoughtful return to fundamental principles will stimulate debate, and perhaps even revive the guidelines movement.

  • 1. We must choose clinical issues which deserve guidelines carefully. Every problem does not need a guideline. Guideline development should marry clinical need and informed research.
  • 1a. As a corollary, we should have two levels of guidelines – guidelines for generalists and guidelines for subspecialists. As a generalist I need a concise evaluation of the key common issues related to a problem For example, when considering atrial fibrillation, I want to know several things: clinical evaluation for etiology, when to cardiovert, how to achieve rate control, when to anticoagulate, when to refer. A cardiologist may want guidelines which involve advanced electrophysiology or indications for antiarrythmics.
  • 2. Guideline panels should reflect intended users. Thus, if we want guideline to inform generalist practice the panel should have a majority of generalists. The panel could include subspecialists, but the generalists should insure that the guidelines remain practical and usable.
  • 3. Guidelines should consider patients with other medical conditions. Thus, a diabetes guideline should include an understanding of the impact of CAD or CHF. Guidelines which consider one disease may or may not pertain when patients have multiple diseases.
  • 4. Guidelines should prioritize the recommendations. For example, if I were developing a CHF guideline, I would prioritize in this approximate order: #1 establish the diagnosis (Echo), #2 treat systolic dysfunction with ACE-I or ARB (and a discussion of dosing), #3 add beta blockage (usually carvedilol), #4 diurese to keep patient euvolemic – avoid volume contraction, #5 consider adding sprionolactone in selected patients, #6 indications for AICD, #7 indications for biventricular pacing, #8 when to consider referral for possible transplantation.
  • 5. Produce readable guideline documents. Generalists do not have time to read long tomes.
  • 6. Have guidelines sponsored through an independent agency. This could be a government agency, or an independent group. We should divorce funding from sources which have a stake in the guideline (i.e., no company which provides drugs for treating hyperglycemia should fund diabetes guidelines).

These represent my first thoughts. I suspect you readers will make some good suggestions for modification or expansion. Please share these thoughts, and I will gladly modify my reinvention plan.

Thanks for the many thoughtful comments as I have explored these issues over the past 2 weeks!

free viagra
buy viagra online
generic viagra
how does viagra work
cheap viagra
buy viagra
buy viagra online inurl
viagra 6 free samples
viagra online
viagra for women
viagra side effects
female viagra
natural viagra
online viagra
cheapest viagra prices
herbal viagra
alternative to viagra
buy generic viagra
purchase viagra online
free viagra without prescription
viagra attorneys
free viagra samples before buying
buy generic viagra cheap
viagra uk
generic viagra online
try viagra for free
generic viagra from india
fda approves viagra
free viagra sample
what is better viagra or levitra
discount generic viagra online
viagra cialis levitra
viagra dosage
viagra cheap
viagra on line
best price for viagra
free sample pack of viagra
viagra generic
viagra without prescription
discount viagra
gay viagra
mail order viagra
viagra inurl
generic viagra online paypal
generic viagra overnight
generic viagra online pharmacy
generic viagra uk
buy cheap viagra online uk
suppliers of viagra
how long does viagra last
viagra sex
generic viagra soft tabs
generic viagra 100mg
buy viagra onli
generic viagra online without prescription
viagra energy drink
cheapest uk supplier viagra
viagra cialis
generic viagra safe
viagra professional
viagra sales
viagra free trial pack
viagra lawyers
over the counter viagra
best price for generic viagra
viagra jokes
buying viagra
viagra samples
viagra sample
generic cialis
cheapest cialis
buy cialis online
buying generic cialis
cialis for order
what are the side effects of cialis
buy generic cialis
what is the generic name for cialis
cheap cialis
cialis online
buy cialis
cialis side effects
how long does cialis last
cialis forum
cialis lawyer ohio
cialis attorneys
cialis attorney columbus
cialis injury lawyer ohio
cialis injury attorney ohio
cialis injury lawyer columbus
prices cialis
cialis lawyers
viagra cialis levitra
cialis lawyer columbus
online generic cialis
daily cialis
cialis injury attorney columbus
cialis attorney ohio
cialis cost
cialis professional
cialis super active
how does cialis work
what does cialis look like
cialis drug
viagra cialis
cialis to buy new zealand
cialis without prescription
free cialis
cialis soft tabs
discount cialis
cialis generic
generic cialis from india
cheap cialis sale online
cialis daily
cialis reviews
cialis generico
how can i take cialis
cheap cialis si
cialis vs viagra
generic levitra
levitra attorneys
what is better viagra or levitra
viagra cialis levitra
levitra side effects
buy levitra
levitra online
levitra dangers
how does levitra work
levitra lawyers
what is the difference between levitra and viagra
levitra versus viagra
which works better viagra or levitra
buy levitra and overnight shipping
levitra vs viagra
canidan pharmacies levitra
how long does levitra last
viagra cialis levitra
levitra acheter
comprare levitra
levitra ohne rezept
levitra 20mg
levitra senza ricetta
cheapest generic levitra
levitra compra
cheap levitra
levitra overnight
levitra generika
levitra kaufen

Comments (4)

Perhaps better: we should publish quidelines for DOCTORs (and their patients) rather than lawyers, insurers and industry interests. They’ve become a “if you play, we’ll pay” document – hence their length…

The next logical step, after guideline reform, is to assure that similar rigor and transparency apply to the construction of the quality measures that are used to allow patients and other stakeholders to assess quality. If those measures are developed covertly by parties with substantive economic interests, then the more nuanced considerations embedded within the guideline can be undermined by the measurement tools.

While simplistic, any guideline should be for the benefit of the patient. This needs to be the clear stated goal, and slavish adherence may in fact work against the patient’s well being, and general health.

Stefan Kertesz comments are appropriate, not only for his point, but for the other external factors that may drive the decision making process. Doctors need to be aware of the subtle pressures working their way into their practices that impact their decision-making processes.

#6 is important given the financial complexity of today’s pharmaceutical industry. Comments have also highlighted the behavioral aspect of guidelines and the desire for other than financial gain.

Guidelines are not rules. They may, in fact, offer a very desirable target for a population, but may be inappropriate for the individual.

Steve Lucas

I second Steve. One should never forget that guidelines are there to guide i.e. recommend, not dictate. When insurers or employers or even governments hear about the guidelines – usually from journalists – they interpret it as requirements. Lacking the knowledge of even basic statistics they confuse cost-effectiveness expressed as cost of QALY with cost-savings and feel justified in forcing everyone to follow guidelines with potentially detrimental effects to an individual (and no benefit to society, even increased cost).

Post a comment