Tuesday, March 13, 2012

Should You Trust Practice Guidelines?

A big part of ObamaCare projected savings is based on physicians adhering to "practice guidelines", using so-called "evidence based medicine". These sound good in theory -- after all, what doctor wants to be against "evidence"?

But how solidly grounded are these guidelines?

A 2009 article from The Journal of the American Medical Association (JAMA) sounds a cautionary note, "Scientific Evidence Underlying the ACC/AHA Clinical Practice Guidelines".

The article opens:
Clinical practice guidelines are systematically developed statements to assist practitioners with decisions about appropriate health care for specific patients' circumstances.​ Guidelines are often assumed to be the epitome of evidence-based medicine. Yet, guideline recommendations imply not only an evaluation of the evidence but also a value judgment based on personal or organizational preferences regarding the various risks and benefits of a medical intervention for a population.
But after going through cardiology practice guidelines issued from 1984 to September 2008, they conclude:
Recommendations issued in current ACC/AHA clinical practice guidelines are largely developed from lower levels of evidence or expert opinion. The proportion of recommendations for which there is no conclusive evidence is also growing.
In particular, many guidelines are just expert "opinion", which may be subject to classic problems of bias, group-think, or conflict-of-interest:
The presence of a large proportion of recommendations with no supporting data from randomized clinical trials requires careful judgment by guideline authors. In such circumstances, the potential for authors' conflicts of interest, real or perceived, may be important. Recommendations based only on expert opinion may be prone to conflicts of interest because, just as clinical trialists have conflicts of interests, expert clinicians are also those who are likely to receive honoraria, speakers bureau, consulting fees, or research support from industry.
Government officials are pushing doctors to follow published guidelines as if they were some sort of "gold standard", yet many of them are lead not gold. (JAMA link via Dr. Art Fougner.)

Dr. Richard Amerling and co-authors make a similar point in their 2008 article, "Guidelines have done more harm than good":
Practice guidelines have proliferated in medicine but their impact on actual practice and outcomes is difficult, if not impossible, to quantify. Though guidelines are based largely on observational data and expert opinion, it is widely believed that adherence to them leads to improved outcomes. Data to support this belief simply does not exist. If guidelines are universally ignored, their impact on treatment and outcomes is minimal.

The incorporation of guidelines into treatment protocols and performance measures, as is now common practice in nephrology, increases greatly the likelihood that guidelines will influence practice and hence, outcomes. Practice patterns set up this way may be resistant to change, should new evidence emerge that contradicts certain recommendations.

Even if guidelines are entirely appropriate, a 'one-size-fits-all' approach is likely to benefit some, but not all. Certain patients may be harmed by adherence to specific guidelines. Guidelines certainly do not encourage clinicians to consider and treat each patient as an individual. They are unlikely to stimulate original research. They are created by a process that is artificial, laborious and cumbersome. This all but guarantees many guidelines are obsolete by the time they are published. Guidelines are produced with industry support and recommendations often have a major impact on sales of industry products.
See also his related 2011 AAPS talk:

Under ObamaCare, government will attempt to enforce standardized medical practice amongst physicians through various financial carrots and sticks, such as government-sanctioned "Accountable Care Organizations".

Dr. Donald Berwick (President Obama's former head of Medicare) has explicitly said as much on multiple occasions. For example:
The primary function of regulation in health care, especially as it affects the quality of medical care, is to constrain decentralized, individualized decision making.
And this:
I would place a commitment to excellence—standardization to the best-known method—above clinician autonomy as a rule for care.
In other words, he and his allies want government to dictate how physicians can practice, because they think they know what's best for you as a patient. They wish to be able to override the judgment of your personal physician who actually knows your medical history, your symptoms, your drug allergies, and your individual preferences.

There's mounting evidence that federal nutrition guidelines have made Americans less healthy, rather than more healthy.

Should we trust the government to do any better in foisting centralized clinical practice guidelines on American physicians?