It’s more of a guideline

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This post accompanies the talk I gave at the Victorian Emergency Clinical Care Network (ECCN) event at the MCG in Melbourne. My remit was to talk about the role of clinical practice guidelines within the context of paediatric emergency medicine.

What is a guideline?

Clinical practice guidelines (CPG) are supposed to be recommendations designed to improve patient care, based, ideally, on a systematic review of the literature. They should cover both the benefits and harms of treatment and discuss a variety of treatment options.

The idea is that if you have to manage a condition that you have little practical experience in managing then you can follow a CPG, whether it is a local one, a statewide one or one produced by a learned body, and safely manage the patient in front of you.

One way to think of a CPG is that it is a recipe.  I bake a cake roughly once a year.  I’m pretty sure I know the ingredients and the proportions but I don’t want to leave anything to chance. Rather than turn my wife’s birthday cake into a Pinterest fail I follow the recipe and leave little to chance.

 

What a guideline is not

…..the code is more what you’d call “guidelines” than actual rules.

Captain Barbossa, Pirates of the Caribbean: The Curse of the Black Pearl (2003)

They are also not protocols. A protocol is a much more rigid framework for the management of a specific condition.

 

Who creates the guidelines?

The concern is always that guidelines are created by GOBSAT (Good Old Boys Sitting Around a Table) rather than experts in the subject matter.

 

How are they created?

First a relevant clinical topic is chosen. Then a group is chosen to create the guideline. Having declared their conflicts of interest openly there should be a systematic review of the topic in hand.  This summary of the literature should be graded according to the strength of the evidence available using a tool such as the GRADE methodology.

What is the GRADE approach

It’s the Grading of Recommendations Assessment, Development and Evaluation method. Evidence is rated in terms of quality (high, medium or low) as well as strength of recommendations (strong or weak)

With all the evidence at their fingertips the team then write their guideline (well, the first draft at least) before it undergoes multiple iterations of the peer review process. Only then, once all parties are as happy as they can be, will it be disseminated and, hopefully, implemented.

You can take a look at how the NICE guidelines are developed here.

 

Why are they useful?

CPG’s have a number of aims.

  • Improve or optimize care
  • Standardize practice and thus act as a focus for quality control and audit
  • Improve knowledge utilization

There are also secondary cost-saving benefits that shouldn’t, but do, come into play.One of the problems of not sticking to guidelines is the potential for patient harm and wastage of precious resources. Estimates suggest that up to $1 trillion US dollars are wasted  on therapies that do not improve the health of the patient.

 

Why don’t we stick to them?

With an abundance of clinical practice guidelines available why don’t we adhere to them? Often there is a gap between what we know and what we practice.

I wrote, briefly, about why we don’t stick to guidelines here but some of the key reasons bear repeating.

Patient factors

Sometimes patients want something that we just cannot provide.  Articles in the popular press may suggest a treatment that is neither feasible nor recommended but parents might want it because the Daily Fail said so.

Physician factors

Lack of awareness of the availability of guidelines

With CPG’s available for a limited number of problems it can be a challenge to know which have guidelines attached. In out time poor lives, can we be expected see if one exists for every patient we meet?

Lack of familiarity with guidelines

Even knowing that they exist does not mean that any given clinician is aware of their content or has access to them at the point of patient care.

Lack of agreement with guidelines

Get three cardiologists in a room to interpret an ECG and you’ll get four different opinions. One concern is that using CPG’s turns the practice of medicine into something akin to ‘cookbook medicine‘. I’ve alluded to the fact that it can be helpful to follow a recipe if you’ve not baked a cake before but should you be following a recipe in order to prepare every meal? Emergency medicine would soon become boring if you entered a diagnostic term into a computer and it spat out the checklist to follow every single time.

Lack of auto-effectiveness

Perhaps, as Choudry et al. suggest you can’t teach an old physician new tricks. They found an inverse relationship between quality care (as defined by adherence to CPG’s) and physician age.

Lack of success expectations

If you don’t think that a CPG is going to make a difference to the patient in front of you then you are unlikely to follow them.

Inertia

Anyone who has tried to lose weight or quit smoking knows that change is hard and sticking to the status quo is easy.

Organizational factors

Jeanne Lenzer gives an account of how guidelines might be biased towards manufacturers given that 71% of chairs of clinical policy and 90.5% of co-chairs had financial conflicts of interests. We saw an example of this in the recent NEJM regarding prolonged use of antibiotics for the treatment of otitis media.  In this study the lead author holds patents for the recommended treatment.

 

Let’s look at an important example, adherence to asthma management guidelines.  Asthma is an incredibly common diagnosis so one would hope that we would all be sticking to the recommendations. A US, survey-based study of primary care providers found that though 70% were aware of national guidelines, only 39% actually stuck to them. Paediatricians fared little better. They gave a variety of reasons for non-compliance to different components of the guidelines.

Corticosteroid prescription – lack of agreement

Cabana et al. give a number of examples including respondents being unhappy with the lack of long-term outcome data with regard to the use of steroids in childhood. This was coupled with an inability to quash parental fears regarding steroid use.

Use of peak flow meters – lack of self-efficacy and outcome expectancy

Whilst there is some disagreement regarding the utility of peak flow meters in the long term, the distinct possibility that patients wouldn’t bother doing the measurements has lead to some physicians not even bothering to suggest it as a management step.

Counselling parents about smoking – lack of self-efficacy

Most paediatricians do not feel comfortable in prescribing or at least suggesting smoking cessation adjuncts and so might not even start the conversation. There is also the (valid) concern that such an activity takes time that may not be available in a busy practice.

Paediatricians didn’t follow the guidelines because they were not confident in their ability to teach how to use a peak flow meter or their ability to help parents quit smoking!

 

Peter Provonost suggests five key measures that might improve guideline adherence and use.

  • The guideline should be headed by a checklist of key practices, rather than convoluted pathways.
  • Barriers, such as disagreement, ambiguity or clinician inertia, should be identified early.
  • They should integrate with other existing guidelines so that doubling up of items does not occur.
  • Guidelines should help drive system change as well as individual change.
  • Guideline developers should look outside of their own sphere of knowledge for assistance.

So, moving forward, what does this mean for those of us using clinical practice guidelines. I would suggest that they need to adhere to a couple of simple principles.

The key authors should be identifiable and their conflicts of interests declared

There should be a planned review date with every practice guideline, where possible

The NHMRC provides a great guide to creation and implementation of clinical practice guidelines here, which is well worth a read if you are thinking of creating your own or just wondering how to best implement and existing guideline.

Conflict of Interest: The author received departmental funding from the Victorian Paediatric Care Network to carry out research into the usability of the statewide clinical practice guidelines.

References

Field MJ, Lohr KN (Eds). Guidelines for clinical practice: from development to use. Institute of Medicine, Washington, D.C: National Academy Press, 1992.

Ebben RH, Vloet LC, Verhofstad MH, Meijer S, Mintjes-de Groot JA, van Achterberg T. Adherence to guidelines and protocols in the prehospital and emergency care setting: a systematic review. Scandinavian journal of trauma, resuscitation and emergency medicine. 2013 Feb 19;21(1):9.

Mercuri M, Sherbino J, Sedran RJ, Frank JR, Gafni A, Norman G. When guidelines don’t guide: the effect of patient context on management decisions based on clinical practice guidelines. Academic Medicine. 2015 Feb 1;90(2):191-6

Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: The relationship between clinical experience and quality of health care. Ann Intern Med. 2005;142:260–273.

Lenzer J. Why we can’t trust clinical guidelines. BMJ. 2013 Jun 14;346(58):f3830.

Pronovost PJ. Enhancing physicians’ use of clinical guidelines. JAMA. 2013 Dec 18;310(23):2501-2.

Grimshaw J, Freemantle N, Wallace S, Russell I, Hurwitz B, Watt I, Long A, Sheldon T. Developing and implementing clinical practice guidelines. Quality in Health care. 1995 Mar;4(1):55.

Wisnivesky JP, Lorenzo J, Lyn-Cook R, Newman T, Aponte A, Kiefer E, Halm EA. Barriers to adherence to asthma management guidelines among inner-city primary care providers. Annals of Allergy, Asthma & Immunology. 2008 Sep 30;101(3):264-70.

Weisz G, Cambrosio A, Keating P, Knaapen L, Schlich T, Tournay VJ. The emergence of clinical practice guidelines. Milbank Quarterly. 2007 Dec 1;85(4):691-727.

Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, Rubin HR. Why don’t physicians follow clinical practice guidelines?: A framework for improvement. JAMA. 1999 Oct 20;282(15):1458-65.

Cabana MD, Rand CS, Becher OJ, Rubin HR. Reasons for pediatrician nonadherence to asthma guidelines. Archives of pediatrics & adolescent medicine. 2001 Sep 1;155(9):1057-62.

Cabana MD, Ebel BE, Cooper-Patrick L, Powe NR, Rubin HR, Rand CS. Barriers pediatricians face when using asthma practice guidelines. Archives of pediatrics & adolescent medicine. 2000 Jul 1;154(7):685-93.

 

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An Emergency Physician with a special interest in education and lifelong learning. When not drinking coffee and reading Batman comics he is playing with his children.

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