Blog | Thursday, March 13, 2014

Guidelines have consequences--intended and unintended


For years on this blog I have expressed my frustration with the guideline movement. Today I am once again angry. This article spurred my anger: Hypertension Guidelines: Clear as Mud

I left this comment on the Medscape site:

“The problem is really more complex than presented. The problem resides in the belief that we should always have a guideline. Some medical issues deserve guidelines, e.g., ACE or ARB (if tolerated) for CKD with proteinuria, statin therapy for secondary prevention in CAD, but many other questions are much more complex and trying to force a guideline for those issues has been and will continue to be a mistake.”

“We must stop insisting on calling expert opinions guidelines. We should only call something a guideline when the data are very clear and we really have consensus on those data.”

“Why distinguish between guidelines and expert opinion? Guidelines are often turned into performance metrics. Guidelines often give us targets to achieve. Expert opinion allows for differences. When the answer is not clear, just do not call it a guideline. The term guideline leads to consequences both intended and unintended. We should admit our differences and not hold practicing physicians to a standard when we have differences. Of course this uncertainty, which all physicians must accept and manage, means that we cannot define “quality”. Perhaps our “quality measures” are really arbitrary. We reward or penalize physicians based on measures that are not really evidence based. Adopting the position that I advocate will bother many, but most practicing physicians would embrace the difference.”

Too many people believe that we can define excellent medical decision making. They want to compare patients with airplanes. They want to believe that we can write rules in the form of: if BP is greater than X, then you should prescribe our drug.

Sorry, but medical decision making is very complex. Patients have many problems, many variables, and 1 size does not fit all. We can define some clear best practices, but in the absence of pristine evidence, we should avoid issuing guidelines. We must allow for medical disagreement and a lack of explicit guidelines.

Some issues deserve multiple opinions. Trying to shoehorn this complexity into a precise guideline leads to unintended consequences. Some examples include the famous 4-hour pneumonia rule, overly tight control for diabetes, overly tight control of hypertension and hormone replacement for all post-menopausal women. In each of these situations, the data used were easily critiqued, yet demanding guidelines led to significant unintended consequences.

Why will the medical establishment not rally to this understanding?

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.