Clinical Guidelines:Clinical Guidelines: Are they changing practice?Are they changing practice?

J. Stephen HuffEmergency Medicine and Neurology

University of Virginia Charlottesville, Virginia

Goals of Practice GuidelinesGoals of Practice Guidelines

• Improve efficiency• Decrease variation• Save money• Safe

• Protect patients• Protect practitioners

Goals of Practice GuidelinesGoals of Practice Guidelines

• Guidelines are “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.”

Field MJ, Lohr MU, eds: Clinical Practice Guidelines: Directions for a New Program. National Academy Press, 1990

When Guidelines might be of use…When Guidelines might be of use…

• Infrequent events with poor outcomes

• Frequent clinical events with diagnostic uncertainty

• Frequent clinical events with therapeutic uncertainty

When Guidelines might be of use…When Guidelines might be of use…

• Infrequent events with poor outcomes

• ACLS- cardiac pathways-pro

-con

• Spinal cord and steroid use….

When Guidelines might be of use…When Guidelines might be of use…

• Infrequent events with poor outcomes

• Spinal cord and steroid use….

“I believe steroids are harmful and without benefit, yet I give them when indicated to avoid litigation.”

-anonymous

When Guidelines might be of use…When Guidelines might be of use…

• Frequent clinical events with

diagnostic uncertainty• Ottawa ankle rules• chest pain• pulmonary embolism• minor head injury

When Guidelines might be of use…When Guidelines might be of use…

• Frequent clinical events with therapeutic uncertainty• community acquired pneumonia• deep venous thrombosis • headache

Guideline chaos…exampleGuideline chaos…example

• University of Virginia 2002University of Virginia 2002• 100 clinical guidelines100 clinical guidelines• 1/3 out of date1/3 out of date• 1/3 infrequently used1/3 infrequently used• 1/3 used frequently by many 1/3 used frequently by many

providers…providers…

Guideline chaos….Guideline chaos….

• University of Virginia 2002

Plan- Scrap most of them….• Focus on 5 frequent scenarios…

Pain, DVT, CAP, Detox, vent care

• Multidisciplinary / cross-service input• Informatics • Feedback

Are clinicians using guidelines?Are clinicians using guidelines?

Yes and no…

High risk scenarios…

Unclear clinical situations….

Are clinicians using guidelines?Are clinicians using guidelines?-modified from Bleck TP: BMJ 321 (7255):239-modified from Bleck TP: BMJ 321 (7255):239

Alternative evidence rating scale ;)

Class 0: Things I believe

Class 0a: Things I believe despite the data

Class 1: Randomized controlled clinical trials that agree with what I believe…

Class 2: Other prospectively collected data

Class 3: Expert opinion

Class 4: Other data that disagrees with me

Class 5: What you believe that I don’t

Why not ?Why not ?

“…specific clinical circumstances”

-may not apply at individual level

-not generalizable

Wears RL. Headaches from Clinical Guidelines Ann Emerg Med. 2002; 39:334

Headaches from Clinical Guidelines Headaches from Clinical Guidelines Wears RL Ann Emerg Med. 2002; 39:334 Wears RL Ann Emerg Med. 2002; 39:334

Commenting on report that emergency physicians do not follow guidelines for treating benign headaches(Vinson DR: Ann Emerg Med 2002;39:215)

-lack of awareness and familiarity-specialty body formulation

Headaches from Clinical Guidelines Headaches from Clinical Guidelines Wears RL Ann Emerg Med. 2002; 39:334 Wears RL Ann Emerg Med. 2002; 39:334

-inertia-inertia

-current practice acceptable, effective-current practice acceptable, effective

-not a problem that needs solving….-not a problem that needs solving….

““Change will occur rapidly if changing Change will occur rapidly if changing solves a problem for the clinician.”solves a problem for the clinician.”

• Element of diagnostic uncertainty with headaches in the ED….but the guidelines are specific for migraine….

…rational to withhold treatment in presence of diagnostic uncertainty…

Headaches from Clinical Guidelines Headaches from Clinical Guidelines Wears RL Ann Emerg Med. 2002; 39:334 Wears RL Ann Emerg Med. 2002; 39:334

• General objection to idea of guidelines…• cookbook• art of medicine

Headaches from Clinical Guidelines Headaches from Clinical Guidelines Wears RL Ann Emerg Med. 2002; 39:334 Wears RL Ann Emerg Med. 2002; 39:334

• 3 legitimate, philosophical arguments that have not been discussed….• Feedforward guidance• Application of aggregate to

individuals• Variation may not be bad…

Headaches from Clinical Guidelines Headaches from Clinical Guidelines Wears RL Ann Emerg Med. 2002; 39:334 Wears RL Ann Emerg Med. 2002; 39:334

• What is a good strategy for success of guidelines?• Does current behavior need to be

changed?• What is the problem with decision-

making?• How to effect change?• Didactic presentations ? Coercive?

Headaches from Clinical Guidelines Headaches from Clinical Guidelines Wears RL Ann Emerg Med. 2002; 39:334 Wears RL Ann Emerg Med. 2002; 39:334

Questions?Questions?