variations in variability

Grubenhoff, Joe Joe.Grubenhoff at CHILDRENSCOLORADO.ORG
Tue Nov 1 20:45:15 UTC 2016


An interesting line of discussion. There are some guidelines that seem incredibly evidence-based (e.g. which kids need a head CT to rule out serious IC injury after head trauma) versus those where there is little (and often conflicting evidence) to support recommendations (Zurich Concussion guidelines). Somehow we manage to beat our colleagues over the head with both types (usually in hindsight Monday-morning QBing) and never acknowledge their flaws. I agree that they are starting point but must be thought of as guides and not prescriptive.

An interesting article worth reading on this subject comes from Greenhalgh and colleagues:
Greenhalgh T, et al. 6 Biases against patients and carers in evidence-based medicine. BMC Medicine (2015) 13:200

I attached as it is open access I believe.

So much of the evidence that informs these guidelines is driven by RCTs in which the study design drives out the variability in the participant population in order to study the intervention in isolation yet that group almost never represents our patient population.

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Joe Grubenhoff, MD, MSCS| Associate Professor of Pediatrics
Section of Emergency Medicine | University of Colorado
Children's Hospital Colorado
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From: Sommers, Lucia [mailto:Lucia.Sommers at UCSF.EDU]
Sent: Tuesday, November 01, 2016 1:43 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] variations in variability

My guess is with the habits you describe, Peter, and those of your colleagues, you will be sorely missed!
To what degree do you think in today's primary care world this type of collaborative engagement goes on?
To encourage it in the San Francisco Bay Area, through the Family & Community Medicine Department at UCSF, over ten years ago, we developed 'Practice Inquiry Colleague Groups' where primary care clinicians get together regularly in their practices to discuss case-based dilemmas and hear follow-up on cases previously presented.
Of course we struggle with getting people to give up a lunch hour once or twice a month to do it.  Incentives in some of the groups (e.g., Kaiser sites) offer free lunch and CME; a couple of the Sutter Health System sites let clinicians block their schedules for up to two patients. (At the latter site, the admin types see this as burn-out prevention.)

Lucia Sommers


From: Elias Peter [mailto:pheski69 at GMAIL.COM]
Sent: Tuesday, November 01, 2016 11:46 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] variations in variability

I retired from active practice at the end of 2015, and have not yet accustomed myself to taking in the past tense.

Our practice was tight knit and we had these conversations regularly, in hallways, over lunch, at the end of the day, and at our almost-monthly journal clubs. It started as a daily habit when there were only 2 of us and we had to 'sign out' inpatients and active outpatients at the beginning and end of every day. We grew to 10 clinicians and eventually used our local hospitalist team and stopped doing inpatient work, but the habit had become part of our culture and persisted. We daily discussed a patient or two with a colleague and frequently presented a patient to one or two others. We often saw each other's patients to meet patient needs or deal with acute illness, which also generated discussions. On occasion we would have the patient formally see someone else in the practice specifically to get a different perspective.

These were both prospective and retrospective discussions, and we discussed victories, defeats, and errors.

Peter

On 2016.11.01, at 2:35 PM, Sommers, Lucia <Lucia.Sommers at ucsf.edu<mailto:Lucia.Sommers at ucsf.edu>> wrote:

Peter, do you ever have the opportunity of talking about these ' carefully considered individual decisions (made collaboratively with patients)' with your practice colleagues? This could be either to get their input before you go forward with a decision or after the fact, like sharing practice anecdotes. I'm wondering about whether talking more about how we do this blending of evidence and experience in the context of real cases wouldn't help validate this critically important skill.

Lucia Sommers



Sent from my iPad

On Nov 1, 2016, at 11:14 AM, Elias Peter <pheski69 at GMAIL.COM<mailto:pheski69 at GMAIL.COM>> wrote:
If there was anything I have learned from 40 years in primary care, it is that guidelines represent the opinions of a group of people who have read and are informed by the evidence. The evidence is always incomplete and always changing, often not applicable to individuals who differ from study groups, and sometimes biased. Neither the evidence nor the guidelines can incorporate the values, preferences or resources of individual patients.

For me, this was both one of the great challenges and one of the great joys of primary care: using the guidelines and the evidence) to start a conversation with a patient about what decision we should make. I never see the guilders as an answer, always as an opening statement.

Sorry for the rant, but many years of being admonished or punished by administrators, insurers, QI committees because of carefully considered individual decisions (made collaboratively with patients) that were deemed 'out of compliance' or 'poor care' has left me with a very sensitive and exposed nerve.

Peter

On 2016.11.01, at 1:30 PM, Twest54973 <000000040134e744-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG<mailto:000000040134e744-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>> wrote:

Guidelines are ideally based on prospective data not just opinion or biologic plausibility
When adequate data doesn't exist ( as is the case for VTE prevention in pregnancy), then different people and organizations create different "guidelines" based on their beliefs and biases

Its a shame (but not unexpected) that different professional associations act independently of each other : this  results in confusion in clinicians and even sometime active conflict between clinicians

A contrary editorial accompanied the Natl Partnership article ...

Good luck to the bedside clinician trying to provide good clinical care!

Thomas Westover MD
Asst Professor Maternal Fetal Med and Obgyn
Cooper Medical School
NJ


Sent from my iPhone

On Nov 1, 2016, at 10:13 AM, Tom Benzoni <benzonit at GMAIL.COM<mailto:benzonit at GMAIL.COM>> wrote:
A topic for awareness/discussion is guidelines.
They need to support the person on the sharp end of the process, the practitioner advising the patient.
So is it acceptable that there is variation among guidelines for the same condition?
Would this be acceptable in other high risk industries?
An example crossed my desk this morning:
Comment
The variability among professional societies' recommendations for VTE prevention in pregnancy has hampered attempts at quality improvement. The NPMS challenges obstetric units to adopt all the features of this bundle in an endeavor to reduce the burden of maternal morbidity and mortality, both of which are disproportionately borne by poor women and those of color. Ideally, efforts to streamline recommendations and encourage measurement of important outcomes will promote equity and excellence in maternity care.
http://www.jwatch.org/na42624/2016/10/28/another-maternal-safety-bundle-obstetric-venous?ijkey=VLA13UO7mZVBs&keytype=ref&siteid=jwatch&variant=full-text
Is it not abrogation of responsibility to push this off onto the practitioner?
How do you reconcile this?
(There are legion examples of this in medicine.)
tom



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