Archive for the ‘medical guidelines’ Category

Medical Guidelines and Medical Consensus-II

Friday, February 8th, 2008

Most consensus policies are still achieved by selection of expert panels or organizations whose opinions conform to each other. Far too many professionals, insurance companies and other healthcare organizations are eager to follow the latest schematic orthodoxy, whether it be the “standard” for treating advanced cancer, or the decision to perform invasive studies. These so-called “Medical Guidelines” are often far from uniform or consistent.

A few years ago in the Lancet, an editorial pointed out that The American Medical Association listed 2200 guidelines, and that within 6 weeks in the same year two governmentally sponsored groups issued opposing guidelines on screening mammography. There continue to be multiple guidelines for mammography as well as prostate and other cancer screening. For example, guidelines for colon cancer screening differ between the National Cancer Institute and the American Cancer Society as well as the American Society for Gastroenterological Endoscopy. Up to 50% of cardiologists in a previous national study disagreed on indications for invasive studies. When ill-conceived guidelines like the preference for early upper endoscopy over the barium X-ray, edge into “Community Standards of Care” they cause untold medical mischief, if not economic havoc. Far too often they express specialty bias and by implication economic self-interest. A study reported in the Journal of The American Medical Association, reported that 72-90% of physicians writing clinical practice guideline articles show conflict of interest.

Consensus, according to Webster, is “agreement in the judgment or opinion reached by a group as a whole.” Despite the problems of bias and self-interest, clearly the practice of medicine cannot exist without a considerable degree of consensus. The democratization of medical opinion has been on balance a powerful and useful, if not a breathtaking development. Darryl F. Zanuck, the film producer once remarked, “If two men on the same job agree all the time, then one is useless. If they disagree all the time, then both are useless.” Unlike pornography and pestilential politics, you don’t necessarily know medical consensus when you see it, since it depends so much on who is doing the talking, and perhaps why.

Medical Guidelines and Medical Consensus-I

Thursday, February 7th, 2008

A climatic change has occurred in the practice of medicine, resulting from the changing economics of healthcare delivery and a new participant mentality. This has been driven by professional organizations and especially the Government. This conceptual shift was accelerated by the Medical Guidelines Movement in the United States in the mid-1980’s when thanks to the emergence of “evidence-based medicine”, a major area of policy focuses on “Outcomes and Effectiveness and Technology Assessment.” Thus was born The Agency for Health Care Policy and Research (AHCPR) who has invited just about everyone from health care organizations to other public- and private-sector entities to submit their clinical practice guidelines for inclusion in the National Guideline ClearinghouseTM (NGC), a comprehensive electronic database.”

In addition to these and other Government-sponsored sites, physicians, health plans, patients, and hospitals are constantly deluged by an archipelago of professional societies and organizations, mostly devoted to their own area of interest, submitting and issuing periodic guidelines and consensus opinions. You’ll be pleasantly surprised by NGC’s very candid disclaimer, though defined in the most compelling Governmental officialese, says in part:

“The NGC database contains evidence-based clinical practice guidelines as defined by the Institute of Medicine (IOM):

    “Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.” (Sounds groundbreaking, doesn’t it?, but hang on.)

These guidelines are not fixed protocols that must be followed, but are intended for health care professionals and providers to consider. (My emphasis) If you require more reassurance, see the Federal Register, the final word on Governmental regulations having legal effect. Federal Register (CFR Vol. 63 no. 70) officially defines Clinical Practice Guidelines, but publishes not a single guideline.Should We Worry?

Most consensus policies are still achieved by selection of expert panels or organizations whose opinions conform to each other. Far too many professionals, HMO’s, and other healthcare organizations, even sophisticated patients, are eager to follow the latest schematic orthodoxy, whether it be the “standard” for treating advanced cancer, or the decision to perform invasive studies. These standards, described as “Medical Guidelines” are often far from uniform or consistent.

More tomorrow…