variations in variability

Edward Winslow edbjwinslow at GMAIL.COM
Tue Nov 1 21:43:42 UTC 2016


Striving for consistency in "Guidelines" is really a problem. In
Cardiovascular disease, where there are probably more fairly good  data
than in almost any specialty, there end up being multiple sets of
guidelines. When I was researching this for my blog, I found that there are
MULTIPLE sets of guidelines for the most common cardiac clinical
conditions. The data from the National Guideline Clearing House is
overwhelming and in a state of flux:

*                                Some Cardiac Conditions with Guidelines at
NGCH*

Number of Guidelines

September ‘15            October ‘15            November ‘15

Hypertension                            442
468                               486
Heart Failure                            369
515                                517
Myocardial Infarction                201
230                               230
Peripheral vascular disease    151
151                                188
Atrial Fibrillation                       108
108                                129
Angina                                       78
78                                  86
Aortic Aneurysm                        53
53                                  59


We might almost call this a "Tower of Babel".  It is no wonder that in
conditions where there are less data than CV that there are conflicting
guidelines. As has been pointed out, there are often then Guidelines that
are based on "Expert Opinion". However, as the table demonstrates, even
with data there must be significant "expert opinion", much of which is
potentially biased. One could ask how much of the variability in the
several sets of Guidelines is related to biases of different experts.

On Tue, Nov 1, 2016 at 4:00 PM, Sommers, Lucia <Lucia.Sommers at ucsf.edu>
wrote:

> See the attached for another pertinent article out of Greenhalgh's shop.
>
> Lucia Sommers
>
>
>
> *From:* Grubenhoff, Joe [mailto:Joe.Grubenhoff at childrenscolorado.org]
> *Sent:* Tuesday, November 01, 2016 1:45 PM
> *To:* Society to Improve Diagnosis in Medicine; Sommers, Lucia
> *Subject:* RE: [IMPROVEDX] variations in variability
>
>
>
> 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.
>
>
>
> *[image: Sig1]*
>
>
> *Joe Grubenhoff, MD, MSCS| Associate Professor of Pediatrics  *Section of
> Emergency Medicine | University of Colorado
>
> Children's Hospital Colorado
>
> 13123 East 16th Avenue, Box 251  |  Anschutz Medical Campus  |  Aurora, CO
> 80045 | Phone: (303) 724-2581 | Fax: (720) 777-7317
>
> joe.grubenhoff at childrenscolorado.org
>
>
> *Connect with **Children's Hospital Colorado*
> <http://www.childrenscolorado.org/>* on **Facebook*
> <http://www.facebook.com/childrenshospitalcolorado> *and **Twitter*
> <http://twitter.com/childrenscolo>
>
>
> [image: CHC_Logo_E-Mail_Color.jpg]
>
> *For a child’s sake…*
>
> *                We are a caring community called to honor the sacred
> trust of our patients, families and each other through *
>
> *                humble expertise, generous service and boundless
> creativity. *
>
> *…This is the moment.*
>
>
>
> *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 <pheski69 at GMAIL.COM>]
> *Sent:* Tuesday, November 01, 2016 11:46 AM
> *To:* 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> 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> 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> 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> 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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-- 
*Edward B, J. Winslow, MD, MBA*
Home 847 256-2475; Mobile 847 508-1442
edbjwinslow at gmail.com
winslowmedical.com

"The only thing new in the world is the history that you don't know"
       Harry S. Truman, 33rd President of US (1945-1953)


"... it can be argued that underinvestment in assessing the past is likely
to
lead to faulty estimates and erroneous prescriptions for future action."
        Eli Ginzberg, 1997






Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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