Limitations of Clinical Practice Guidelines
Summary
TLDRIn 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
- π Clinical practice guidelines are intended to optimize patient care based on systematic reviews and evidence assessments.
- π Subjective judgments are inherent in guideline development, which can introduce errors and biases.
- π° Conflicts of interest, often financial or intellectual, are common in guideline panels and can affect guideline trustworthiness.
- π Many conflicts of interest are not reported, leaving users unaware of potential biases in the recommendations.
- π Poor development of guidelines is a significant issue, with few following established guidelines for development.
- π€ Single specialty panels can lead to a lack of diverse perspectives and shared biases in guideline creation.
- π Information overload is a concern, with an overabundance of guidelines potentially diluting their effectiveness.
- π¨ββοΈ Guidelines often lack flexibility, offering a one-size-fits-all approach that doesn't account for patient comorbidities.
- βοΈ There's an overreliance on expert opinion within guidelines, which should not be confused with evidence-based recommendations.
- β οΈ 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
π₯ 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.
π« 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.
Mindmap
Keywords
π‘Clinical Practice Guidelines
π‘Subjective Judgments
π‘Conflict of Interest
π‘Guidelines Development
π‘Single Specialty Physicians
π‘Information Overload
π‘One-Size-Fits-All
π‘Expert Opinion
π‘Performance Measurement
π‘Clinical Judgment
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
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