Tuesday, March 01, 2005

Two insightful articles on Guidelines and why they should not be a major indication of "quality"

An excellent article by Tinetti et al in the December 30, 2004 NEJM explains problems with guidelines particularly as disease specific guides are applied to patients with multiple illnesses. The second article is in The New Yorker by Atul Gawande and deals specifically with cystic fibrosis centers which apparently are a guideline dominated enterprise and how the very best such places go beyond guidelines. Guidelines are great for folks who purport to measure quality because they are easy to use. It recalls the old story that talks about the drunk who searched for his lost keys under the street light- not because he lost them there but because it was the easiest place to look. Some of the pitfalls Tinnetti writes about are:1) the guidelines are often based on RCTs(often with relatively small improvements in relative risks) that have cherry picked subjects who do not have other illnesses,and exclude older people and go for a relatively short times whereas in real life patients have many problems , get old and take pills for a long time.2) patients with several illnesses might just not have the same priorities as the trialists and may opt to not take all of the meds that Multiple guidelines offer,3) multiple drugs have multiple interactions.Extrapolating from RCTs that exclude many of the patients actually seen by doctors to recommendations about those patients seems to involve more faith based that evidence based medicine.Worse yet, physicians who have philosophical problems with those extrapolations may be judged to not be practicing quality medicine. The issue here is should RCTs' conclusions be construed narrowly- ie to those only like the participants in the study- or broadly -ie to include patients whose characteristics would have not allowed them to be eligible for the trial. Perhaps older more experienced physicians are more able to see when guidelines are appropriate and when they are not: when patient preferences and other variables trump the guideline's suggestions.
Quality assurance programs have as a given that variations are not desirable but there are appropriate variations due to the various specificities of the patients and the patient's own preferences. QA programs assume variations are bad. Gawande's article make the point that something more than adherence to guidelines makes a program great. It seems that it has something to do with having a great doctor involved: one who understands the basis for the guidelines and knows when to innovate and improvise. So much of medical care is improvisation by the physician and the patient. There is a sense in which QA program miss that point entirely.

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