Terrence M. Shaneyfelt

Reassessment of clinical practice guidelines: go gently into that good night.

IN 1990, THE INSTITUTE OF MEDICINE PROPOSED GUIDEline development to reduce inappropriate health care variation by assisting patient and practitioner decisions. Unfortunately, too many current guidelines have become marketing and opinion-based pieces, delivering directive rather than assistive statements. Current use of the term guideline has strayed far from the original intent of the Institute of Medicine. Most current articles called “guidelines” are actually expert consensus reports. It is not surprising, then, that the article by Tricoci et al in this issue of JAMA demonstrates that revisions of the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines have shifted to more class II recommendations (conflicting evidence and/or divergence of opinion about the usefulness/efficacy of a procedure or treatment) and that 48% of the time, these recommendations are based on the lowest level of evidence (level C: expert opinion, case studies, or standards of care). This trend is especially disconcerting given the quantity of cardiovascular scientific literature published during the last decade. The overreliance on expert opinion in guidelines is problematic. All guideline committees begin with implicit biases and values, which affects the recommendations they make. However, bias may occur subconsciously and, therefore, go unrecognized. Converting data into recommendations requires subjective judgments; the value structure of the panel members molds those judgments. Guideline consumers could adjust for these biases if guideline panels made their values and goals explicit, but usually they remain opaque. The most widely recognized bias is financial. Guidelines often have become marketing tools for device and pharmaceutical manufacturers. While the ACC and AHA receive no industry funding for guideline development, they do receive industry support to disseminate guideline products such as pocket guides. Financial ties between guideline panel members and industry are common. “Experts” on guideline panels are more likely to receive industry funding for research, consulting fees, and speakers’ honoraria. In 1 study of 44 guidelines, 87% of the guideline authors had some form of industry tie. Other biases are also important. The specialty composition of a guideline panel likely influences guideline development. Specialty societies can use guidelines to enlarge that specialty’s area of expertise in a competitive medical marketplace. Federal guideline committees may focus on limiting costs; committees influenced by industry are more likely to shape recommendations to accord with industry needs. Guidelines have other limitations. Guidelines are often too narrowly focused on single diseases and are not patient focused. Patients seldom have single diseases, and few if any guidelines help clinicians in managing complexity. Paradoxically, guidelines are also often too comprehensive, covering every possible intervention that could be appropriate for a patient with that single disease. Tricoci et al found that in ACC/AHA guidelines with at least 1 revision, the number of recommendations increased 48% from the first guideline to the most recent version. If there is a main message in such guidelines, it is likely to be lost in the minutiae. Guidelines are not patient-specific enough to be useful and rarely allow for individualization of care. Most guidelines have a one-size-fits-all mentality and do not build flexibility or contextualization into the recommendations. There are simply too many guidelines, often on the same topic. For instance, clinicians really do not need 10 different adult pharyngitis guidelines. Moreover, guidelines are often out of date. The evidence base used to create guidelines changes quickly. Most guidelines become outdated after 5 years, and most guideline developers lack formal procedures for updating their guidelines. The ACC/AHA guidelines are periodically updated, with updates taking a mean of 4.6 to 8.2 years until publication. As a result, many clinicians do not use guidelines. An even greater concern, however, is that some of these consensus statements are being turned into performance measures and other tools to critique the quality of physician care. This potential problem could be minimized if performance measures were derived from high-quality guidelines based on the highest level of evidence and applied to patients with a

Evaluating the teaching of evidence based medicine: conceptual framework

Although evidence for the effectiveness of evidence based medicine has accumulated, there is still little evidence on what are the most effective methods of teaching it.

NCCN Guidelines Insights: Prostate Cancer Early Detection, Version 2.2016

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Prostate Cancer Early Detection provide recommendations for prostate cancer screening in healthy men who have elected to participate in an early detection program. The NCCN Guidelines focus on minimizing unnecessary procedures and limiting the detection of indolent disease. These NCCN Guidelines Insights summarize the NCCN Prostate Cancer Early Detection Panels most significant discussions for the 2016 guideline update, which included issues surrounding screening in high-risk populations (ie, African Americans, BRCA1/2 mutation carriers), approaches to refine patient selection for initial and repeat biopsies, and approaches to improve biopsy specificity.

Association of consultation between generalists and cardiologists with quality and outcomes of heart failure care

BACKGROUND The appropriate roles for generalists and cardiologists in the care of patients with heart failure (HF) are unknown. The objective of this retrospective cohort study was to determine whether consultation between generalists and cardiologists was associated with better quality and outcomes of HF care. METHODS We studied left ventricular function evaluation (LVFE) and angiotensin-converting enzyme inhibitor (ACEI) use and 90-day readmission and 90-day mortality rates in patients with HF who were hospitalized. Patient care was categorized into cardiologist (solo), generalist (solo), or consultative cares. The processes and outcomes of care were compared by care category using logistic regression analyses fit with generalized linear mixed models to adjust for hospital-related clustering. RESULTS Of the 1075 patients studied, 13% received cardiologist care, 55% received generalist care, and 32% received consultative care. More patients who received consultative care (75%) received LVFE than patients who received generalist care (36%) and cardiologist care (53%; P <.001). Fewer patients who received solo care (54% each) received ACEI compared with 71% of patients who received consultative care (P <.001). After multivariable adjustment, consultative care was associated with higher odds of LVFE than generalist care (adjusted odds ratio [OR], 6.06; 95% CI, 3.97-9.26) or cardiologist care (adjusted OR, 2.96; 95% CI, 1.70-5.13) care. Consultation was also associated with higher odds of ACEI use compared with generalist (adjusted OR, 2.42; 95% CI, 1.42-4.12) or cardiologist (adjusted OR, 2.32; 95% CI, 1.14-4.72) care. Compared with patients who received generalist care, patients who received consultative care had lower odds of 90-day readmission (adjusted OR, 0.54; 95% CI, 0.34-0.86). CONCLUSION Collaboration between generalists and cardiologists, rather than solo care by either, was associated with better HF processes and outcomes of care.

Core Competencies in Evidence-Based Practice for Health Professionals: Consensus Statement Based on a Systematic Review and Delphi Survey

Importance Evidence-based practice (EBP) is necessary for improving the quality of health care as well as patient outcomes. Evidence-based practice is commonly integrated into the curricula of undergraduate, postgraduate, and continuing professional development health programs. There is, however, inconsistency in the curriculum content of EBP teaching and learning programs. A standardized set of minimum core competencies in EBP that health professionals should meet has the potential to standardize and improve education in EBP. Objective To develop a consensus set of core competencies for health professionals in EBP. Evidence Review For this modified Delphi survey study, a set of EBP core competencies that should be covered in EBP teaching and learning programs was developed in 4 stages: (1) generation of an initial set of relevant EBP competencies derived from a systematic review of EBP education studies for health professionals; (2) a 2-round, web-based Delphi survey of health professionals, selected using purposive sampling, to prioritize and gain consensus on the most essential EBP core competencies; (3) consensus meetings, both face-to-face and via video conference, to finalize the consensus on the most essential core competencies; and (4) feedback and endorsement from EBP experts. Findings From an earlier systematic review of 83 EBP educational intervention studies, 86 unique EBP competencies were identified. In a Delphi survey of 234 participants representing a range of health professionals (physicians, nurses, and allied health professionals) who registered interest (88 [61.1%] women; mean [SD] age, 45.2 [10.2] years), 184 (78.6%) participated in round 1 and 144 (61.5%) in round 2. Consensus was reached on 68 EBP core competencies. The final set of EBP core competencies were grouped into the main EBP domains. For each key competency, a description of the level of detail or delivery was identified. Conclusions and Relevance A consensus-based, contemporary set of EBP core competencies has been identified that may inform curriculum development of entry-level EBP teaching and learning programs for health professionals and benchmark standards for EBP teaching.

Acute ischaemic colitis associated with oral phenylephrine decongestant use

In this case, the authors have presented for the first time that ischaemic colitis may be associated with phenylephrine use. Since phenylephrine is the more common active ingredient in over-the-counter (OTC) cold medications, other presentations may follow this case. A MEDLINE search was performed for all case reports or case series of ischaemic colitis secondary to pseudoephedrine or phenylephrine use published between 1966 and 2013. The search resulted in four case reports and one case series describing patients with acute onset ischaemic colitis with exposure to pseudoephedrine immediately prior to onset. However, we found no case reports of ischaemic colitis associated with phenylephrine use. We present this case as an unexpected clinical outcome of phenylephrine, which has not been associated with ischaemic colitis in the literature. Also, this case serves as a reminder of the important clinical lesson to question all patients’ use of OTC and prescribed medications.