variations in variability

Hoffer, Edward P.,M.D. EHOFFER at MGH.HARVARD.EDU
Wed Nov 2 11:04:19 UTC 2016


Guidelines fall along a spectrum. At one end are those which carefully review the literature and give strength of evidence for each recommendation. At the other are GOBSAT guidelines: Good Old Boys Sitting Around a Table.  I much prefer the former, but as has been noted, for many conditions (eg SBE prophylaxis for dental procedures), there simply is no good data.
Another factor which is often forgotten is that many of the guideline writers have serious conflicts of interest. Many are heavily paid by Big Pharma to lecture and consult, and have an inherent bias towards drug treatment. If you are a diabetologist, it is clearly in your interest to lower the threshold of sugar at which diabetes is diagnosed, thereby creating millions of more diabetics.
Ed
Edward P Hoffer MD, FACP, FACC

From: Elias Peter [mailto:pheski69 at GMAIL.COM]
Sent: Tuesday, November 01, 2016 2:05 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] variations in variability

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



________________________________

Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>

To unsubscribe from IMPROVEDX: click the following link:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1

or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG>

Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX


Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine

To learn more about SIDM visit:
http://www.improvediagnosis.org/


________________________________

Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>

To unsubscribe from IMPROVEDX: click the following link:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1

or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG>

Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX


Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine

To learn more about SIDM visit:
http://www.improvediagnosis.org/



________________________________

Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>

To unsubscribe from IMPROVEDX: click the following link:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG>

Visit the searchable archives or adjust your subscription at: http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX

Moderator:David Meyers, Board Member, Society for Improving Diagnosis in Medicine

To learn more about SIDM visit:
http://www.improvediagnosis.org/


The information in this e-mail is intended only for the person to whom it is
addressed. If you believe this e-mail was sent to you in error and the e-mail
contains patient information, please contact the Partners Compliance HelpLine at
http://www.partners.org/complianceline . If the e-mail was sent to you in error
but does not contain patient information, please contact the sender and properly
dispose of the e-mail.


To unsubscribe from the IMPROVEDX:
mail to:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
or click the following link: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG

Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG

For additional information and subscription commands, visit:
http://www.lsoft.com/resources/faq.asp#4A

http://LIST.IMPROVEDIAGNOSIS.ORG/ (with your password)

Visit the searchable archives or adjust your subscription at:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX

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

To unsubscribe from the IMPROVEDX list, click the following link:<br>
<a href="http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1" target="_blank">http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1</a>
</p>

HTML Version:
URL: <../attachments/20161102/56fed5b5/attachment.html>


More information about the Test mailing list