Is my doctor’s guideline for my treatment right for me?

Is my doctor’s guideline for my treatment right for me? – Melissa J. Armstrong, MD | March 11, 2017

Health care guidelines are produced in ever-increasing numbers. The National Guideline Clearinghouse, a U.S.-based public website compiling summaries of “clinical practice” (health care) guidelines, has over 1,000 entries and is updated weekly. The National Institute for Health and Care Excellence in the U.K. has over 180 clinical guidelines.

Health care guidelines impact policy decisions and care for individuals. Recent research, though, suggests that the public has only a vague understanding of what guidelines are and how they are developed.

Current high-quality clinical practice guidelines, though, are anchored in a thorough review of available medical evidence.

This was certainly not the case with the CDC Guidelines (see CDC Manipulated Data to Deceive, Contradictions in CDC Guidelines, and Updated: Evidence Against CDC Opioid Guidelines)  

The development of these guidelines was a demonstration of how biased and hidden agenda-driven writers can create a  guideline with wide-ranging social consequences without the slightest investigation or penalty.

In this era of evidence-based medicine, various standards exist for developing clinical practice guidelines. These include standards from the Guidelines International Network and the U.S.-based Institute of Medicine. The Appraisal of Guidelines Research & Evaluation Enterprise (AGREE) publishes a tool to assess the quality and reporting of clinical practice guidelines.

Guidelines summarize what is known (and not known) about different tests and treatments for health problems. They then make recommendations for expected best care, with specific descriptions of how confident guideline developers are in the research and recommendations.

High quality guidelines are developed by groups of patients and other public representatives, professional subject experts (physicians and other health professionals) and guideline specialists. These individuals decide what questions to ask, examine all the available research, grade the research quality, consider other issues (such as risks, benefits, availability, personal preferences and sometimes cost), and then make recommendations about best medical care

The reliance of guidelines on the best medical evidence means the recommendations are now less likely to be driven by panel members’ opinions and personal experiences.

Again, the CDC Guidelines show how this is no longer true.

Practicing health professionals and the public can be more confident that recommendations are based largely on unbiased reviews of medical research and transparent weighing of benefits and harms.

Limitations

The term “clinical practice guideline” is reserved to describe “recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.”

Even when guidelines are based on systematic grading of the medical evidence, sometimes different developers make different recommendations.

When the guideline developers all have the same strong opinion, agenda, or financial interest, that “systematic grading” gets manipulated until it supports the desired, not the actual, scientific “proof”.

These conflicts are confusing for patients and for health professionals.

Inconsistencies may reflect

  • different approaches to panel composition,
  • reviewing and grading medical evidence,
  • interpretation of the evidence and/or
  • weighing of risks and benefits.

The inconsistencies may also represent more concerning possibilities such as contributions from conflicts of interest.

Putting guidelines to good use

A common misunderstanding about clinical practice guidelines is that they tell patients and health professionals what to do. 

No, the CDC guidelines specifically “tell doctors what to do”.

Rather than identifying one “best” answer, clinical practice guidelines summarize what is known about medical options and describe anticipated benefits and risks.

This information can then be used by patients and health professionals during shared decision making, which combines patients’ values and preferences alongside the best medical evidence to make an individualized decision.

There’s no “shared decision making” when it comes to opioids. The CDC guidelines took the patient entirely out of the picture.

Every medical decision is a personal one, and rarely is there a single “right answer.”

Not according to all the “addiction specialists” – they have one answer for every person in every situation: NO OPIOIDS.

Trustworthy clinical practice guidelines are an important tool for improving the delivery of high quality health care to a broad audience. Individual decisions, though, are best made when patients partner with their health professionals to understand the evidence and incorporate their own medical history and values to make the best decision in that unique circumstance.

This is exactly what is NOT happening. Patients are being forced to give up their only pain relief without any consideration of the impact this will have on their functionality and quality of life.

Author: Melissa J. Armstrong is a neurologist. This article was originally published on The Conversation. Read the original article.
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