Avoid premature performance standards

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Category : Medical Rants

This tweet inspired this post:

“@ACSmaggus: This history of peri-operative beta-blockade is a good case for allowing evidence to mature before changing practice http://t.co/jPZwrJG5JG”

or

Learning from mistakes in clinical practice guidelines: the case of perioperative ?-blockade

Unfortunately, I do not have access to the entire article, but this quote stands out.

On one level, what may be most remarkable about the rise and fall of preoperative ?-blocker guidelines is how unremarkable it seems. Preoperative ?-blockade is only one of several recent examples in which expert endorsements of promising therapies changed markedly when new evidence highlighted potential harms that had been overlooked by these endorsements.

Most experienced physicians learn not to believe the first reports of anything. When new pharmaceuticals arrive, we delay rapid acceptance. Too often the initial reports are over enthusiastic.

This phenomenon also occurs with research. My first NEJM article was a refutation of a clinical prediction rule. Inability to predict relapse in acute asthma.

My good friend Sandy Schwartz taught us this with a brilliant abstract presentation at the Society for Medical Decision Making in 1981. He had developed a decision rule, but after the abstract was accepted for presentation, he found that retesting the rule with fresh data yielded a failed rule.

Science is a process. Scientists do studies, report them, then other scientists check the results. Especially when the results do not make sense, we need further studies.

Declaring a new performance standard prematurely can have (drum roll please) UNINTENDED CONSEQUENCES. We talk often about ill-advised performance measures. This article should influence guideline writers and performance measurement developers. We must continue to question research findings and argue against premature adoption of practice standards. The emperor is not always clothed.

Comments (1)

The question must also be asked of how to change doctor’s behavior once new information is available. The Sept. 22, 2014 print version of The Wall Street Journal highlights Gynecologist Resist FDA Over Popular Surgical Tool.

This article highlights the continued use of the laparoscopic power morcellator in the removal of fibroids and the potential for spreading undetected cancer.

The article reports of doctors dismissing study findings and encouraging patients to use this method of fibroid removal even after FDA guidelines warns against its use.

Doctors need to be willing to abandon old ways in favor of proven information that they may in fact be putting patients at risk. An additional issue is the impact on practice income, which should never ever be a consideration in patient care where increased risk is involved.

Steve Lucas

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