Limitations of Clinical Practice Guidelines

Summary

In this video, Terry Shane discusses the limitations and potential issues with clinical practice guidelines, which are meant to optimize patient care but can be influenced by subjective judgments and biases. He highlights the common problem of financial and intellectual conflicts of interest, often unreported, and the poor development of many guidelines. Shane also points out that guideline panels tend to be composed of single-specialty physicians, leading to a lack of diverse perspectives. Furthermore, he criticizes the one-size-fits-all approach and the overemphasis on expert opinion, which should not be confused with evidence-based guidelines. Shane concludes by emphasizing the need to view guidelines as flexible tools to guide, rather than rigid rules.

Takeaways

• 📚 Clinical practice guidelines are intended to optimize patient care based on systematic reviews and evidence assessments.
• 🔍 Subjective judgments are inherent in guideline development, which can introduce errors and biases.
• 💰 Conflicts of interest, often financial or intellectual, are common in guideline panels and can affect guideline trustworthiness.
• 🙈 Many conflicts of interest are not reported, leaving users unaware of potential biases in the recommendations.
• 📉 Poor development of guidelines is a significant issue, with few following established guidelines for development.
• 🤔 Single specialty panels can lead to a lack of diverse perspectives and shared biases in guideline creation.
• 📚 Information overload is a concern, with an overabundance of guidelines potentially diluting their effectiveness.
• 👨‍⚕️ Guidelines often lack flexibility, offering a one-size-fits-all approach that doesn't account for patient comorbidities.
• ⚖️ There's an overreliance on expert opinion within guidelines, which should not be confused with evidence-based recommendations.
• ⚠️ Guidelines have become too directive, turning into rules rather than remaining as flexible guides for clinical practice.

Q & A

What are clinical practice guidelines according to the Institute of Medicine?

Clinical practice guidelines are statements that include recommendations intended to optimize patient care, informed by systematic review of the evidence and an assessment of the benefits and harms of alternative care options.

Why do subjective judgments in guideline development lead to potential problems?

Subjective judgments in guideline development can lead to potential problems because they introduce room for error and bias, which can result in untrustworthy or biased guidelines.

What is the most significant limitation of clinical practice guidelines mentioned in the script?

The most significant limitation mentioned is conflict of interest, particularly financial and intellectual conflicts, which can influence the recommendations made in the guidelines.

Why might industry sponsorship of guidelines lead to a conflict of interest?

Industry sponsorship can lead to a financial conflict of interest because the industry may have a vested interest in the outcomes of the guidelines, potentially influencing the recommendations to favor their products or services.

How prevalent are conflicts of interest among guideline panel members, according to a study mentioned in the script?

According to a study mentioned in the script, almost 90% of guideline panel members have some conflict of interest.

What are some ways conflicts of interest are managed in guideline development?

Conflicts of interest are managed in various ways, including excluding members with conflicts or having members declare their conflicts. However, these methods do not necessarily reduce the impact of conflicts on the guideline development process.

Why might guidelines developed by single specialty physicians be problematic?

Guidelines developed by single specialty physicians can be problematic because they may lack a multidisciplinary perspective, leading to recommendations that are not comprehensive or that do not consider the broader context of patient care.

What is the issue with having too many guidelines covering too many issues?

Having too many guidelines covering too many issues can lead to information overload, making it difficult for healthcare providers to prioritize and implement the most important recommendations, potentially leading to confusion and reduced effectiveness.

How can the 'one-size-fits-all' approach in guidelines be problematic for patient care?

The 'one-size-fits-all' approach in guidelines can be problematic because it does not account for individual patient differences, comorbidities, or the need for clinical judgment, potentially leading to inappropriate or less effective care.

Why should expert opinion not be labeled as a guideline?

Expert opinion should not be labeled as a guideline because guidelines imply a level of evidence-based recommendations, whereas expert opinion is based on individual experience and may not have the same level of evidence to support it.

What is the main message from Captain Barbossa in the Pirates of the Caribbean that relates to clinical practice guidelines?

The main message from Captain Barbossa is that guidelines should be more like guidelines than rules, meaning they should guide rather than dictate care, allowing for flexibility and clinical judgment.

Outlines

00:00

🏥 Limitations of Clinical Practice Guidelines

The paragraph discusses the limitations and potential issues with clinical practice guidelines, which are intended to optimize patient care but can be flawed. It emphasizes that while guidelines are meant to convert evidence into actionable recommendations, they often involve subjective judgments that can introduce bias and errors. The speaker highlights the common problem of financial and intellectual conflicts of interest, especially when industry sponsors are involved. It's noted that many panel members have such conflicts, which are not always disclosed, leading to potential bias in recommendations. Furthermore, the paragraph points out that many guidelines are poorly developed, not following established guidelines for their creation, and that guideline panels are often composed of single-specialty physicians, which can lead to a lack of diverse perspectives. The issue of information overload due to an excessive number of guidelines is also mentioned, as well as the tendency for guidelines to be overly prescriptive rather than flexible, and the over-reliance on expert opinion instead of evidence.

05:01

🚫 Overemphasis on Guidelines as Rules

This paragraph addresses the concern that clinical practice guidelines are often treated as rigid rules rather than flexible guides. It critiques the practice of turning expert opinions into performance measurements, which can lead to a lack of trust and usefulness among physicians. The speaker uses a metaphor from the movie 'Pirates of the Caribbean' to illustrate that guidelines should be more like guidelines than strict rules. The paragraph concludes by suggesting that the video has provided insights into the criticisms and limitations of clinical practice guidelines and invites viewers to contact the speaker for further questions or discussions.

Keywords

💡Clinical Practice Guidelines

Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. In the video, the speaker discusses the limitations and problems associated with these guidelines, emphasizing that while they aim to optimize patient care, they are not without flaws. The video highlights how guidelines can be influenced by subjective judgments and biases, which can lead to untrustworthy recommendations.

💡Subjective Judgments

Subjective judgments refer to the personal opinions or interpretations that individuals make when evaluating information. The video points out that the creation of clinical practice guidelines involves subjective judgments, which can introduce errors and biases. This is a critical issue because it can affect the reliability and trustworthiness of the guidelines, as the speaker suggests that these judgments are often not transparent and can lead to conflicts of interest.

💡Conflict of Interest

A conflict of interest arises when an individual's private interests or relationships could potentially interfere with their professional judgment or actions. The video emphasizes that financial and intellectual conflicts of interest are common in the development of clinical practice guidelines, with the speaker citing studies that show nearly 90% of guideline panel members have some form of conflict. This can compromise the integrity of the guidelines and make them less trustworthy.

💡Guidelines Development

The development of guidelines involves a process of reviewing evidence, assessing benefits and harms, and formulating recommendations for care. The video criticizes the poor development of many guidelines, noting that they often do not follow established guidelines for development. This lack of adherence to proper development protocols can lead to recommendations that are not as reliable or effective as they should be.

💡Single Specialty Physicians

Single specialty physicians are those who focus on one particular area of medicine. The video discusses how guideline panels often consist of single specialty physicians, which can lead to a narrow perspective and shared biases. This can result in guidelines that may not consider the broader context of a patient's health or the potential interactions between different medical conditions.

💡Information Overload

Information overload occurs when there is too much information to process effectively. The video mentions that there are too many guidelines covering too many issues, leading to information overload. This can make it difficult for practitioners to prioritize and apply the most relevant guidelines, potentially reducing the effectiveness of care.

💡One-Size-Fits-All

The term 'one-size-fits-all' refers to a single approach or solution that is applied to everyone regardless of individual differences. The video criticizes guidelines that adopt a one-size-fits-all approach, arguing that they do not account for the variability in patient needs and conditions. This can result in guidelines that are too directive and do not allow for the necessary flexibility in clinical decision-making.

💡Expert Opinion

Expert opinion is the advice or judgment given by someone with specialized knowledge or experience in a particular field. The video discusses the inclusion of expert opinion in guidelines, noting that while it is sometimes necessary due to a lack of evidence, it should not be confused with evidence-based recommendations. The speaker argues that expert opinion should not be the basis for performance measurements or quality of care judgments.

💡Performance Measurement

Performance measurement is the process of quantifying the efficiency, effectiveness, and quality of services or processes. The video raises concerns about guidelines being turned into performance measurements, suggesting that this can lead to a focus on meeting the guidelines rather than on providing the best care for individual patients. This can result in a misalignment between the guidelines and the actual needs of patients.

💡Clinical Judgment

Clinical judgment refers to the ability of healthcare professionals to make decisions based on their knowledge, experience, and assessment of a patient's condition. The video argues that many guidelines do not leave room for clinical judgment, which is essential for tailoring care to the individual needs of patients. The speaker emphasizes the importance of maintaining clinical judgment in the application of guidelines.

Highlights

Clinical practice guidelines can improve patient care but have limitations and problems.

The Institute of Medicine defines clinical practice guidelines as statements that include recommendations informed by systematic review of evidence.

Subjective judgments in guideline development can lead to errors and bias.

Conflict of interest, particularly financial and intellectual, is a significant limitation in guideline development.

Industry sponsorship of guidelines can lead to financial conflicts of interest.

Up to 90% of guideline panel members may have conflicts of interest, which are often not reported.

Many guidelines are poorly developed and do not follow guidelines for developing guidelines.

Guideline panels often consist of single specialty physicians, leading to shared values and biases.

There is an information overload with too many guidelines focusing on too many issues.

A study in JAMA showed that following all guidelines for a typical patient would result in a high medication burden.

Guidelines often cover too many things instead of focusing on main areas with variability in care.

Guidelines tend to be one-size-fits-all, leaving little room for clinical judgment.

Most guidelines are single disease focused, not accounting for patients with multiple comorbidities.

There is too much expert opinion built into guidelines, which should not be confused with evidence-based recommendations.

Guidelines should be more like Captain Barbossa's view of the pirate code: more guidelines than rules.

Guidelines have turned into rules too often, leading to problems and a lack of trust by physicians.

The video helps understand criticisms and limitations of clinical practice guidelines.

Transcripts

hi Terry Shane you fell for UAB School

of Medicine clinical practice guidelines

can often improve the quality of care

that we provide our patients but they're

not without limitations and problems in

this video I'll go through some of these

limitations and problems which can lead

to untrustworthy biased guidelines so as

a reminder the Institute of Medicine

defined what clinical practice

guidelines are a couple of years ago as

statements that include recommendations

intended to optimize patient care that

are informed by systematic review of the

evidence an assessment of the benefits

and harms of alternative care options

now guidelines go beyond just reviewing

and summarizing evidence like a

systematic review would they convert

evidence into recommendations of care

and because of that as alland etske says

this requires subjective judgments and

whenever subjective judgments are used

at lead room for error and bias and

therein leads some of the problems of

clinical practice guidelines so these

are my views of what are some

limitations of clinical practice

guidelines we'll go through each of

these individually I've written on these

topics before in a variety of editorials

but I just like to hit some of the

highlights so conflict of interest is

probably one of the biggest limitations

of clinical practice guidelines and the

two most common are financial and

intellectual is very common for industry

to sponsor guidelines if industry

doesn't usually a single medical

specialty society sponsors a guideline

and you can hopefully see that that can

lead to a financial conflict of interest

and unfortunately conflict of interest

seems to be very common on guideline

panels variety of studies have shown

different percentages but probably one

of the better done study shows up to

almost 90% of guideline panel members

have some conflict of interest and the

problem is is if we knew what these

conflicts were we may be able to

interpret the recommendations taking

that conflict of interest into account

but unfortunately many conflicts of

interest are not reported in guidelines

so you're left wondering if there's any

conflicts and the recommendations that

the authors make and these conflicts of

interest tend to get quote unquote

manage in a variety ways everything from

excluding members who have conflicts of

interest up to just having people

declare their conflicts of interest but

really declarations of conflict of

interest does nothing to really reduce

the impact of that conflict of interest

on the guideline development process

many guidelines are very poorly

developed and don't follow guidelines

for developing guidelines I showed this

in 1999 and more recently coming than

colleagues in what used to be archives

of internal medicine now JAMA internal

medicine published a study redoing sort

of my earlier study and unfortunately

found the exact same thing that very few

guidelines follow most of the guidelines

and this makes you wonder how

trustworthy the recommendations might be

guideline panels often can put are

composed of single specialty physicians

so for example a group of cardiologists

only and the problem is those same

groups of types of physicians or panel

members doesn't have to be physicians

tend to share the same values and biases

and remember we convert data into

recommendations and that conversion of

data into recommendations is filtered

through our prism of our belief system

and biases now there are too many

guidelines that are focused on way too

many issues and we get lost in

information overload there seems to be a

guideline for everything and you lose

the message at all the minutiae and

there was an interesting study published

in JAMA in 2005 that took what I

consider to be a typical patient I see

in my internal medicine practice and

looked at guidelines that were available

for this particular patient and they

look to see how many medications and

doses and costs etc would occur if you

followed all the guidelines and you can

see this patients hypothetical patient

would have to take a lot of medications

multiple times a day and I'm sure today

it's even worse because we've come up

with some other treatments for these

diseases since this study was done so

really just they're trying to cover too

many things with guidelines instead of

trying to cover the main areas that have

a lot of variability in care the other

problem I see with guidelines is that

they have a one-size-fits-all meant

allottee their way to directive instead

of being a guideline and guiding you on

things that could be do they try to tell

you what you should do on everybody and

unfortunately just like guideline panels

are singled specialty membership most

guidelines are single disease focused

guidelines and patients have multiple

comorbidities usually and these

guidelines leave almost no room for

clinical judgment now there's also too

much expert opinion built into

guidelines that's okay to have expert

opinion because often we need opinion

when there's a lack of evidence but the

problem is we should not label expert

opinion as a guideline

it's just that expert opinion or call it

a consensus statement but guideline is a

very strong term that is often then

converted into a performance measurement

an opinion should not be what we are

guided or I'm sorry what we are judged

upon for quality of care and I think

Captain Barbossa from Pirates of the

Caribbean got it right when Elizabeth

suam was trying to get him to take her

back to shore he pointed out that the

code was more guidelines than rules even

so he must do nothing secondly you must

be a pirate for the Pirates I think

we've forgotten that guidelines are

supposed to be that they're supposed to

guide us but not be rules we've turned

them into rules way too much and I think

it's led to problems with guidelines and

the lack of trust by physicians and lack

of usefulness for many of these

guidelines this video has helped you

understand some of the common criticisms

and limitations of clinical practice

guidelines America have any questions

you can contact me through the course

website or through the contact me

section my blog have a great day