Chapter 003. Decision-Making in Clinical Medicine (Part 11)

Clinical Practice Guidelines According to the 1990 Institute of Medicine definition, clinical practice guidelines are "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances." This definition provides emphasis to several crucial features of modern guideline development. First, guidelines are created using the tools of EBM. In particular, the core of the development process is a systematic literature search followed by a review of the relevant peer-reviewed literature. Second, guidelines are usually focused around a clinical disorder (e.g., adult diabetes, stable angina pectoris) or a health care intervention (e.g., cancer screening). ...
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Chapter 003. Decision-Making in Clinical Medicine (Part 11) Chapter 003. Decision-Making in Clinical Medicine (Part 11) Clinical Practice Guidelines According to the 1990 Institute of Medicine definition, clinical practiceguidelines are systematically developed statements to assist practitioner andpatient decisions about appropriate health care for specific clinical circumstances.This definition provides emphasis to several crucial features of modern guidelinedevelopment. First, guidelines are created using the tools of EBM. In particular,the core of the development process is a systematic literature search followed by areview of the relevant peer-reviewed literature. Second, guidelines are usuallyfocused around a clinical disorder (e.g., adult diabetes, stable angina pectoris) or ahealth care intervention (e.g., cancer screening). Third, guidelines are intended toassist decision-making, not to define explicitly what decisions should be made ina particular situation. The primary objective is to improve the quality of medicalcare by identifying areas where care should be standardized, based on compellingevidence. Guidelines are narrative documents constructed by an expert panel whosecomposition is often chosen by interested professional organizations. These panelsvary in the degree to which they represent all relevant stakeholders. The guidelinedocuments consist of a series of specific management recommendations, asummary indication of the quantity and quality of evidence supporting eachrecommendation, and a narrative discussion of the recommendations. Manyrecommendations have little or no supporting evidence and, thus, reflect the expertconsensus of the guideline panel. In part to protect against errors by individualpanels, the final step in guideline construction is peer review, followed by a finalrevision in response to the critiques provided. Guidelines are closely tied to the process of quality improvement inmedicine through their identification of evidence-based best practices. Suchpractices can be used as quality indicators. Examples include the proportion ofacute MI patients who receive aspirin upon admission to a hospital and theproportion of heart-failure patients with depressed ejection fraction who are on anACE inhibitor. Routine measurement and reporting of such quality indicators canproduce selective improvements in quality, since many physicians prefer not to beoutliers. Conclusions In this era of EBM, it is tempting to think that all the difficult decisionspractitioners face have been or soon will be solved and digested into practiceguidelines and computerized reminders. However, EBM provides practitionerswith an ideal rather than a finished set of tools with which to manage patients. Thesignificant contribution of EBM has been to promote the development of morepowerful and user-friendly EBM tools that can be accessed by the busypractitioners. This is an enormously important contribution that is slowly changingthe way medicine is practiced. One of the repeated admonitions of EBM pioneershas been to replace reliance on the local gray-haired expert (who may be oftenwrong but is rarely in doubt) with a systematic search for and evaluation of theevidence. But EBM has not eliminated the need for subjective judgments. Eachsystematic review or clinical practice guideline presents the interpretation ofexperts whose biases remain largely invisible to the reviews consumers. Inaddition, meta-analyses cannot generate evidence where there are no adequaterandomized trials, and most of what clinicians confront in practice will never bethoroughly tested in a randomized trial. For the foreseeable future, excellentclinical reasoning skills and experience supplemented by well-designedquantitative tools and a keen appreciation for individual patient preferences willcontinue to be of paramount importance in the professional life of medicalpractitioners. Further Readings Balk EM et al: Correlation of quality measures with estimates of treatmenteffect in meta-analyses of randomized controlled trials. JAMA 287:2973, 2002[PMID: 12052127] Del Mar C et al: Clinical Thinking: Evidence, Communication andDecision Making. Malden, Mass., Blackwell, 2006 Grimes DA et al: Refining clinical diagnosis with likelihood ratios. Lancet365:1500, 2005 [PMID: 15850636] Haynes RB et al: Clinical Epidemiology: How to Do Clinical PracticeResearch. Philadelphia, Lippincott Williams & Wilkins, 2006 Peterson ED et al: Association between hospital process performance andoutcomes among patients with acute coronary syndromes JAMA 295:1912, 2006[PMID: 16639050] Reilly BM et al: Translating clinical research into clinical ...