Clinical Practice Guidelines...Is the Tail Wagging the Dog?
No matter the discipline, type of practice, or setting of medicine, clinicians find themselves inundated by clinical practice guidelines that dictate best practices for the patients they serve. Yet why is there so little regulation of such an important commodity in health care? Why does it seem that there is an overabundance of guidelines in certain topical areas, but a complete lack of guidelines in others? Why should we experience confusion, ambiguity, and contradiction while attempting to follow clinical practice guidelines when our diagnostic routines, therapeutic practices, policies, and perhaps even reimbursement are going to be judged based on our adherence to standards?
The National Guideline Clearinghouse (NGC) is maintained as a public resource by the Agency for Healthcare Research and Quality (AHRQ). It serves as a database and vehicle to provide access to clinical practice guidelines for healthcare providers and healthcare delivery systems. The NGC currently maintains guidelines from more than 300 different organizations. Some of the functionalities for the NGC include
- a guideline comparison utility that gives users the ability to generate side-by-side comparisons for two or more guidelines
- guideline syntheses comparing guidelines covering similar topics, highlighting areas of similarity and difference (eg, guidelines developed in different countries).
In 2012, it was reported that the NGC had 471 guidelines on hypertension and 276 on stroke. Why is this necessary? To use an example that hits closer to home for anesthesiologists, blood transfusion and management have multiple published guidelines. Among these include A Clinical Practice Guideline from the AABB (2014), The STS/SCA Blood Conservation Guidelines (2007, 2011), ASA Practice Guidelines for Perioperative Blood Management (2014), The European Society of Anaesthesiology Guidelines for Severe Perioperative Bleeding (2013), Guidelines for RBC Transfusion in Adult Trauma and Critical Care from the Society of Critical Care Medicine (2009), and many others. I don’t suppose it would surprise you to learn that these aforementioned blood management guidelines sometimes conflict and often confuse those trying to adhere to their standards of care.
The Society of Cardiovascular Anesthesiologists (SCA) is also frustrated with the disarray of clinical practice guidelines and the overall lack of compliance to most major guideline recommendations among practitioners. SCA plans to alter this unfortunate reality by beginning 3 major efforts that will help our members and extended medical community to more easily comply with guidelines.
The first step is the creation of the new guidelines subcommittee. This committee is chaired by Dr. Roman Sniecinski and is a part of the SCA Quality and Safety arm. Major goals for the committee are to ensure that SCA is well represented on appropriate guideline projects and that authors are vetted for expertise and possible conflicts of interest.
The second effort involves the creation of new guidelines in areas in which no guidelines currently exist. This has been a major multidisciplinary effort of SCA with the Society of Thoracic Surgeons (STS) and the American Society of Extracorporeal Technology (AmSECT). The result is the manifestation of guidelines that serve as best practices in Perfusion Management. Experts in all three disciplines have joined together and culled the literature in critical areas related to safe practices in cardiopulmonary bypass. The first guideline is “The Society of Thoracic Surgeons, The Society of Cardiovascular Anesthesiologists, The American Society of Extracorporeal Technology Clinical Practice Guidelines for Cardiopulmonary Bypass (CPB): Temperature Management in Cardiopulmonary Bypass”, and summarizes best practices for heating, cooling, and protecting end-organ function during CPB. Other guidelines being created by this interdisciplinary group include anticoagulation management, renal protection, and neurologic protection during extracorporeal perfusion. Each society will have the option to publish in a journal within their specialty thus having 3 simultaneous, identical manuscripts published in the surgical, anesthesiology, and the perfusion literature. Look for these guidelines in the August journal publications.
The third way in which SCA plans to impact guideline management includes our new project, Clinical Practice Improvement (CPI). This project was well-described in my last President’s message but it is timely to mention it now as well. SCA and the SCA Foundation conceived this project in order to maximize compliance with clinical practice guidelines. The project initially will synthesize and summarize a succinct version of all guidelines in a particular topic area and then disseminate this in optimal educational and data-driven formats. The first and most developed of our CPI subgroups is the group addressing postoperative atrial fibrillation, chaired by Dr. Danny Muehlschlegel. This multidisciplinary group, comprised of surgeons, cardiologists, cardiac anesthesiologists, and epidemiologists, will soon simplify the way we diagnose, prevent, and treat postoperative atrial fibrillation.
The discontinuity and redundancy in the publication of clinical practice guidelines must cease. There must be quantity control and proof of necessity for new guidelines to end confusion. Fortunately, our journals have begun to recognize this. SCA is doing what we can to simplify this issue. If you would like any additional information on the SCA guidelines initiatives, the projects mentioned, or would like to volunteer your efforts, feel free to inquire at firstname.lastname@example.org.