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

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). Third, guidelines are intended to "assist" decision-making, not to define explicitly what decisions should be made in a particular situation. The primary objective is to improve the quality of medical care by identifying areas where care should be standardized, based on compelling evidence. Guidelines are narrative documents constructed by an expert panel whose composition is often chosen by interested professional organizations. These panels vary in the degree to which they represent all relevant stakeholders. The guideline documents consist of a series of specific management recommendations, a summary indication of the quantity and quality of evidence supporting each recommendation, and a narrative discussion of the recommendations. Many recommendations have little or no supporting evidence and, thus, reflect the expert consensus of the guideline panel. In part to protect against errors by individual panels, the final step in guideline construction is peer review, followed by a final revision in response to the critiques provided. Guidelines are closely tied to the process of quality improvement in medicine through their identification of evidence-based best practices. Such practices can be used as quality indicators. Examples include the proportion of acute MI patients who receive aspirin upon admission to a hospital and the proportion of heart-failure patients with depressed ejection fraction who are on an ACE inhibitor. Routine measurement and reporting of such quality indicators can produce selective improvements in quality, since many physicians prefer not to be outliers. Conclusions In this era of EBM, it is tempting to think that all the difficult decisions practitioners face have been or soon will be solved and digested into practice guidelines and computerized reminders. However, EBM provides practitioners with an ideal rather than a finished set of tools with which to manage patients. The significant contribution of EBM has been to promote the development of more powerful and user-friendly EBM tools that can be accessed by the busy practitioners. This is an enormously important contribution that is slowly changing the way medicine is practiced. One of the repeated admonitions of EBM pioneers has been to replace reliance on the local "gray-haired expert" (who may be often wrong but is rarely in doubt) with a systematic search for and evaluation of the evidence. But EBM has not eliminated the need for subjective judgments. Each systematic review or clinical practice guideline presents the interpretation of "experts" whose biases remain largely invisible to the review's consumers. In addition, meta-analyses cannot generate evidence where there are no adequate randomized trials, and most of what clinicians confront in practice will never be thoroughly tested in a randomized trial. For the foreseeable future, excellent clinical reasoning skills and experience supplemented by well-designed quantitative tools and a keen appreciation for individual patient preferences will continue to be of paramount importance in the professional life of medical practitioners. Further Readings Balk EM et al: Correlation of quality measures with estimates of treatment effect in meta- analyses of randomized controlled trials. JAMA 287:2973, 2002 [PMID: 12052127] Del Mar C et al: Clinical Thinking: Evidence, Communication and Decision Making. Malden, Mass., Blackwell, 2006 Grimes DA et al: Refining clinical diagnosis with likelihood ratios. Lancet 365:1500, 2005 [PMID: 15850636] Haynes RB et al: Clinic al Epidemiology: How to Do Clinical Practice Research. Philadelphia, Lippincott Williams & Wilkins, 2006 Peterson ED et al: Association between hospital process performance and outcomes among patients with acute coronary syndromes JAMA 295:1912, 2006 [PMID: 16639050] Reilly BM et al: Translating clinical research into clinical practice: Impact of using prediction rules to make decisions. Ann Intern Med 144:201, 2006 [PMID: 16461965] Sanders GD et al: Cost-effectiveness of screening for HIV in the era o f highly active antiretroviral therapy. N Engl J Med 352:570, 2005 [PMID: 15703422] . Chapter 003. Decision-Making in Clinical Medicine (Part 11) Clinical Practice Guidelines According to the 1990 Institute of Medicine definition, clinical practice guidelines are. guidelines are usually focused around a clinical disorder (e.g., adult diabetes, stable angina pectoris) or a health care intervention (e.g., cancer screening). Third, guidelines are intended. little or no supporting evidence and, thus, reflect the expert consensus of the guideline panel. In part to protect against errors by individual panels, the final step in guideline construction