Guidelines for Guidelines

"Guidelines" (like these) drive health leaders, policymakers, politicians and caregivers crazy. They're supposed to describe "evidence-based" "best practices" for diagnosis, treatment and overall management for hundreds of medical problems. Yet, it's been known for years they often go ignored by many practicing physicians who are unaware of them, would rather rely on their individual independent judgment and experience, doubt their validity or would rather continue with what they've done for years.

What's the problem? Is it the guidelines or is it the docs?

Johns Hopkins' Peter Pronovost, writing in the Dec. 5 JAMA wonders if both can be helped with some common sense guidelines for guidelines:

1. Any guideline should prioritize its recommendations (based on patient benefit) and explicitly link them to "time and space" of a specific point in the course of an episode of care  The author points out that it's not uncommon for guidelines to be more than a hundred pages and simply list all the recommendations.

2. Guidelines should identify the barriers to their adoption and recommend strategies for their successful implementation.  Naturally, the developers of these guidelines would need to climb down from their ivory towers and actually think (and maybe perform research) on getting the guideline into the front lines of real-world health care.

3. Guidelines need to contemplate co-existing conditions and stop focusing on single diseases or risks.  In a hospital, it's not unusual for safety checklists to deal with single issues, resulting in dozens of lists.

4. Automate automate automate and use "systems" of care instead of relying on the memory and best intentions of human beings.  Robotics can do a lot of routine monitoring, patient work flows can incorporate safety and docs and nurses should be freed to be..... docs and nurses!

5. Develop "practice strategies" that integrate multi-disciplinary teaming and pools expertise in the related sciences of epidemiology, implementation and engineering.

The DMCB agrees with the ideas and wonders if these recommendations can't also be used by Accountable Care Organizations, health care systems and population-based service providers as they seek to disseminate best practices for the care. It's one thing to "post" or "link" a standard guideline in an intranet or an electronic health record "prompt," it's another to make it useful at the point of care.

"Metabias," the Limits of Evidence Based Medicine and Implications for Disease Management

The font of all wisdom?

It was the Disease Management Care Blog that alerted readers to the term "surveillance bias."  The ever-alert DMCB has found another catch phrase that nicely sums up another limitation of evidence-based medicine (EBM). 

This one is "metabias."

Recall that EBM is the practice of applying the high quality science of peer-reviewed medical literature to day-to-day clinical practice.  Knowing the details of the study populations, the absolute risk improvement, sample sizes and possible biases reported in prestigious medical journals should enable scientist-physicians to divine the "gold standard" of "Level 1" evidence for the betterment of their patients.  The young DMCB grew up on this.  It remembers the hospital "roundsmanship" of debating the latest published clinical trial results before entering patient rooms, much like rabbis debating the finer details of the Talmud.  Heady stuff.

Yet, EBM has had more than its fair share of problems.  Add one more, courtesy of Stephen Goodman and Kay Dickersin, writing in the Annals of Internal Medicine.  They point out that it is not unusual for physicians to "group" all of the published studies about a particular condition and pool the results, in what is commonly referred to as a "meta-analysis."  If, after summing things up, one treatment appears to result in better outcomes versus another, physicians can be more confident about the merits of the treatment, right?

Maybe not.  It turns out that one example of metabias is a "publication" bias.  That describes the phenomenon that authors are more likely to submit and medical journals are more likely to report only "positive" studies.  Contrarian negative studies typically do not see the light of day. Think of it as selective publication.

A new metabias discussed by the authors is the finding that positive studies from single institutions generally show a larger effect of treatment than studies performed in multiple institutions.  One explanation is that solo scientist-investigators may not be subject to the checks and balances of a third party and be unconsciously tilting the execution of the study in a direction that they want. 

In other words, all those prospective randomized clinical trials from single academic institutions may not be much of a gold standard after all. 

No kidding says Alison Stuebe, writing in the July 6 New England Journal.  She was a believer in EBM when she started out, but she quickly found that it didn't quite compare to the wisdom she gained through personal experience. Metabias may be one explanation.

This is important from several perspectives.  The disease and population health management community has long been criticized for the "lack of evidence" that their processes result in greater quality and lower costs.  Maybe the processes for creating that evidence are less robust than generally realized.

Last but not least, the "science" of EBM has a role to play in health care reform, but it is not the answer to all that ails health care.  Much like Dr. Stuebe, we need to be more circumspect about what the medical literature is - and isn't - telling us.