The principal aim of guidelines is to improve the quality and consistency of care. The premise is that guidelines, which promote interventions of proven benefit, will reduce morbidity or mortality. This is not necessarily achieved in daily practice, as guidelines are often not implemented. There is very little evidence that guidelines improve patient outcomes in primary medical care.1
Before even saying that guidelines have the potential to improve care and patient outcomes, it is crucial to ensure that they will be developed to a high quality standard. Standards are well established on transparency, minimizing conflicts of interest, group composition, systematic review of evidence, evidence foundation, writing and rating recommendations, and updating.2 A number of classification schemes have been developed to aid in this process in an attempt, most often, to give an indication of the “strength” of a recommendation. This is called evidence-based medicine. In practising evidence-based medicine, we are attempting to improve the general practice of the science of medicine.
Required expertise
As part of the standards of making guidelines, should we have a debate about group composition? One of the recent debates has been that methodologic experts should be the ones creating guidelines. As you might suspect, this is arising largely from the problem that many guidelines have been paid for by the pharmaceutical industry or have been created by groups with disproportionate representation from individuals with commercial conflicts of interest. Everyone recognizes the need for minimizing conflicts of interest and having methodologic experts participate in guideline creation. However, having guidelines done primarily by methodologic experts is like having a wine steward who does not drink wine. Let’s not create a new problem trying to solve an old one!
The group composition should be balanced, comprising methodologic experts and clinicians. The most recent standards have emphasized the importance of having representatives of the population likely to be affected by the guidelines, such as family physicians (those mostly affected in their practices) and patients (those affected in their care). Family physicians are now elaborating their own guidelines. Is this the right answer to improve evidence-based medicine? To specialists, guidelines developed without their input will not contain all the required expertise. Furthermore, having guidelines developed separately by specialists and family physicians creates the potential risk of contradictory recommendations or debates that can do a disservice to clinical practice and patient care. Debates that sound healthy within the medical community could be potentially damaging on the public stage. Naïve consumers of guidelines, such as government bodies or the payers, might choose to accept the recommendations that suit them best and that primarily serve their economic interest. This can be done without proper consideration of the guidelines’ limitations and potential hazards.
Improving care
Moreover, a more fundamental problem than the creation of guidelines is that guidelines might do little to change practice. Do we have the evidence that guidelines made by family physicians will be better implemented than those made by other specialists? Studies have been done on family physicians’ needs for, attitudes toward, and use of guidelines.3,4 These studies suggest that there is a need for family physician versions to be created and delivered. However, the development of guidelines does not ensure their use in practice. Publication in professional journals or mailing to targeted health care professionals such as family physicians will not lead to changes in professional behaviour (ie, best practice).5,6 There is also need with respect to how information should be supported in its use (ie, implemented in practice).
The most important concern should not be who owns the right to make guidelines but rather improving the quality of care and increasing the likelihood that practice is going to be changed in the right direction. Ideally, guidelines should contain recommendations for implementation. This should be the real debate and it is the real challenge! The responsibility should go beyond making high-quality guidelines; it should be on quality improvement with a structured approach to promoting quality of care.7 More than that, clinical guidelines are only one option for improving the quality of care.
Notes
CLOSING ARGUMENTS — NO
Jean Bourbeau MD MSc FRCPC
It is crucial to ensure that guidelines will be developed to a high quality standard. Guidelines developed without specialist input will not contain all the required expertise.
We do not have evidence that guidelines made by family physicians will be better implemented than those made by other specialists.
The most important concern should not be who owns the right to make guidelines but rather that practice is going to be changed in the right direction.
Footnotes
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Competing interests
None declared
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