guidelines

Elias Peter pheski69 at GMAIL.COM
Mon Dec 12 21:35:38 UTC 2016


The proposal to have clinicians in local institutions or other (fairly large) groups pool their resources to assess guidelines makes sense, but is unlikely to happen.

What I have seen happen is that  the clinicians respond more to the pressures applied by the folks who pay them, most often those same local institutions (who are driven by the desire to live up to national standards and qualify for enhanced revenue by achieving guideline-based metrics).

Peter Elias, MD


> On 2016.12.12, at 4:26 PM, Edward Winslow <edbjwinslow at gmail.com> wrote:
> 
> There has been guideline bloat for some time now. 
> 
> Last year, I did a post on Guidelines, which I titled: "We have “Information Overload” in Clinical Guidelines."  In the post I noted that at the time there were between 442 and 486 guidelines for Hypertension and 369 to 517 for Heart Failure. At that time there were between 108 and 129 sets of guidelines for Atrial Fibrillation. As has been pointed out, the data on which the guidelines are based is not always great AND there are often conflicts of interest among the authors. The observation that the HF guidelines have been rapidly revised, based on a couple of studies, to use a combination Neprilysin inhibitor/ACE inhibitor may be bothersome to some.
> 
> Maybe each group of clinicians (at a hospital or system level) should get together and put their own assessment of the various guidelines and try to get buy in from the majority of the interested parties. As results get more closely scrutinized, the groups with the better guides for practice will become identifiable. This suggestion might put a burden on some of a group, but that can be recognized in the compensation guides.
> 
> How to stop information bloat, including chart bloat, will be a challenge for the next short term. Hopefully, some will work on this problem
> 
> Ted Winslow
> 
> 
> On Mon, Dec 12, 2016 at 11:00 AM, Elias Peter <pheski69 at gmail.com <mailto:pheski69 at gmail.com>> wrote:
> This is a daily (hourly?) dilemma in primary care.
> 
> My personal approach was to have a conversation with the patient about the fact that some people with a great deal of experience but also conflicts of interest had looked at the evidence and published their opinion as to the implications of the evidence, but that it was pretty fuzzy. Then I would explain the options and try to differentiate with the patient which recommendations were unanimous, which were conflicted, which were based on good/bad/no evidence.
> 
> All this, of course, in addition to explaining the complex physiology, pathology, pharmacology, statistics involved. And eliciting the preferences and values of the patient.  And checking the various boxes and accomplishing the various unrelated tasks required by my employer, required of them by regulatory agencies and payors. And saving some time for documenting so that the institution can bill and collect for the work I have done.  And asking the patient if there is anything else they would like to address.
> 
> In a 20 or 30 minute appointment, because I long ago gave up on the 15 minute paradigm.
> 
> Peter Elias, MD
> 
>> On 2016.12.12, at 8:30 AM, Tom Benzoni <benzonit at GMAIL.COM <mailto:benzonit at GMAIL.COM>> wrote:
>> 
>> Group challenge:
>> 3 societies publish guidelines on ER treatment of A fib.
>> ESC, ACC, Canada
>> -Give strong recommendations based on weak evidence (their own finding) of expert opinion, not clinical trials
>> -Among 21 questions addressed, 5 completely different recommendations, 6 partial agreements, 10 agreements
>> -Only 1 group recommended absence of conflict of interest for >50% of its panel.
>> 
>> Thus:
>> 
>> Do you: 
>> -Take the result with which you disagree, find a guideline that agrees with you and pronounce the care bad
>> or
>> -Do the opposite
>> or 
>> Poclaim guidelines are useless and take pity on the person having to select these at the point of care?
>> 
>> tom
>> 
>> 
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> 
> 
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> 
> -- 
> Edward B, J. Winslow, MD, MBA
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> 
> "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
> 
> 
> 







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