Blog | Monday, October 27, 2014

Avoid premature performance standards

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”


Learning from mistakes in clinical practice guidelines: the case of perioperative beta-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 beta-blocker guidelines is how unremarkable it seems. Preoperative beta-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.

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.