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Clinical Guidelines: Are they changing practice?

Clinical Guidelines: Are they changing practice?. J. Stephen Huff Emergency Medicine and Neurology University of Virginia Charlottesville, Virginia. Goals of Practice Guidelines. Improve efficiency Decrease variation Save money Safe Protect patients Protect practitioners.

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Clinical Guidelines: Are they changing practice?

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  1. Clinical Guidelines:Are they changing practice? • J. Stephen Huff • Emergency Medicine and NeurologyUniversity of Virginia Charlottesville, Virginia

  2. Goals of Practice Guidelines • Improve efficiency • Decrease variation • Save money • Safe • Protect patients • Protect practitioners

  3. Goals of Practice Guidelines • Guidelines are “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.” • -Field MJ, Lohr MU, eds: Clinical Practice Guidelines: Directions for a New Program. National Academy Press, 1990

  4. When Guidelines might be of use… • Infrequent events with poor outcomes • Frequent clinical events with diagnostic uncertainty • Frequent clinical events with therapeutic uncertainty

  5. When Guidelines might be of use… • Infrequent events with poor outcomes • ACLS- cardiac pathways • -pro • -con • Spinal cord and steroid use….

  6. When Guidelines might be of use… • Infrequent events with poor outcomes • Spinal cord and steroid use…. • “I believe steroids are harmful and without benefit, yet I give them when indicated to avoid litigation.” -anonymous

  7. When Guidelines might be of use… • Frequent clinical events with • diagnostic uncertainty • -Ottawa ankle rules • -chest pain • -pulmonary embolism • -minor head injury

  8. When Guidelines might be of use… • Frequent clinical events with therapeutic uncertainty • -community acquired pneumonia • -deep venous thrombosis • -headache

  9. Guideline chaos…example • University of Virginia 2002 • 100 clinical guidelines • -1/3 out of date • -1/3 infrequently used • -1/3 used frequently by many providers…

  10. Guideline chaos…. • University of Virginia 2002 • Plan- Scrap most of them…. • Focus on 5 frequent scenarios… • Pain, DVT, CAP, Detox, vent care • Multidisciplinary / cross-service input • Informatics • Feedback

  11. Are clinicians using guidelines? • Yes and no… • High risk scenarios… • Unclear clinical situations….

  12. Are clinicians using guidelines?-modified from Bleck TP: BMJ 321 (7255):239 • Alternative evidence rating scale ;) • Class 0: Things I believe • Class 0a: Things I believe despite the data • Class 1: Randomized controlled clinical trials that agree with what I believe… • Class 2: Other prospectively collected data • Class 3: Expert opinion • Class 4: Other data that disagrees with me • Class 5: What you believe that I don’t

  13. Why not ? • “…specific clinical circumstances” • -may not apply at individual level • -not generalizable • Wears RL. Headaches from Clinical Guidelines Ann Emerg Med. 2002; 39:334

  14. Headaches from Clinical Guidelines Wears RL Ann Emerg Med. 2002; 39:334 • Commenting on report that emergency physicians do not follow guidelines for treating benign headaches • (Vinson DR: Ann Emerg Med 2002;39:215) • -lack of awareness and familiarity • -specialty body formulation

  15. Headaches from Clinical Guidelines Wears RL Ann Emerg Med. 2002; 39:334 • -inertia • -current practice acceptable, effective • -not a problem that needs solving…. • “Change will occur rapidly if changing solves a problem for the clinician.”

  16. Headaches from Clinical Guidelines Wears RL Ann Emerg Med. 2002; 39:334 • Element of diagnostic uncertainty with headaches in the ED….but the guidelines are specific for migraine…. • …rational to withhold treatment in presence of diagnostic uncertainty…

  17. Headaches from Clinical Guidelines Wears RL Ann Emerg Med. 2002; 39:334 • General objection to idea of guidelines… • -cookbook • -art of medicine

  18. Headaches from Clinical Guidelines Wears RL Ann Emerg Med. 2002; 39:334 • 3 legitimate, philosophical arguments that have not been discussed…. • -Feedforward guidance • -Application of aggregate to individuals • -Variation may not be bad…

  19. Headaches from Clinical Guidelines Wears RL Ann Emerg Med. 2002; 39:334 • What is a good strategy for success of guidelines? • -Does current behavior need to be changed? • -What is the problem with decision-making? • -How to effect change? • -Didactic presentations ? Coercive?

  20. Questions?

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