Guidelines in family practice—help wanted

Clinical practice guidelines (CPGs) are important tools for family physicians—but finding the right tools and using them judiciously represent daily challenges. It is no surprise that guidelines, and controversies about them, feature prominently in the pages of Canadian Family Physician.^1–3 Type guidelines into the search function on the journal’s website (www.cfp.ca) and voila …1868 results!

The Institute of Medicine defines CPGs as “statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.”⁴ So if CPGs should be a wonderful resource, why are they not more helpful?

The first problem is the sheer number. The CMA Infobase lists 377 CPGs relevant to family medicine.⁵ After eliminating duplicates and those with limited relevance to general practice, there still remain more than 200 CPGs—a lot to keep in mind! And of course, most CPGs are multifaceted, attempting to provide guidance for a range of clinical situations.

Clinical practice guidelines are promoted as the standard of care and used to measure performance. Evolution of evidence is normal, so we expect that CPGs must be regularly revised. But some have been spectacularly wrong, such as previous recommendations to give postmenopausal hormone replacement or opioids for chronic noncancer pain. This can breed suspicion of guidelines. Family physicians might be reluctant to embrace CPGs because they conflict with other guidelines. Patients might find they do not fit their values. For example, for people diagnosed with type 2 diabetes, the Canadian Diabetes Association CPGs recommend adding medication if hemoglobin A_1c targets are not achieved within 2 to 3 months of lifestyle management.⁶ This does not fit with how long it takes most people to come to grips with a new diagnosis and implement fundamental changes in quotidian routines of eating and activity. The short end of the range conflicts with guidance for the appropriate frequency of measuring hemoglobin A_1c levels.⁷ Recommendations to simultaneously address blood pressure, lipid levels, and cardioprotection invite the hazards of polypharmacy, with potential side effects and drug interactions.

Rigorous analyses of CPGs have revealed multiple problems. A study of guidelines produced from 1985 to 1997 found that the mean adherence to recognized standards was just above 50%.⁸ Sixteen years later, Allan and colleagues wrote that close to half of guidelines were based only on the lowest level of evidence or expert opinion.⁹ After reviewing primary care guidelines in the CMA Infobase, they found that specialists were 3 times more likely to contribute to CPGs than family physicians were and almost twice as likely to report conflicts of interest (48.6% vs 27.7%). Even worse, conflict of interest statements were provided in only 31.1% of these CPGs.⁹ For guidelines that expanded disease definitions, 75% of authors had ties to industry.¹⁰

There have been calls for better CPGs,^11,12 and important medical organizations are addressing these problems.^4,13,14 Essentially, trustworthy CPGs must be developed by multidisciplinary panels of experts and affected groups based on a systematic review that rates the quality of evidence and strength of recommendations, using an explicit and transparent process that minimizes biases and conflicts of interest, and considers patient preferences.

It will take time for current CPGs to incorporate these standards. Indeed, they will be resisted by some providers or industries with vested interests. In the meantime, family physicians will need to exercise judgment when deciding to use CPGs, paying particular attention to the sources, the funders, and the fit with the complexity of real patients.

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