Clinical Guidelines: Are they changing practice? J. Stephen Huff Emergency Medicine and Neurology University of Virginia Charlottesville, Virginia

Goals of Practice Guidelines  Improve efficiency  Decrease variation  Save money  Safe Protect patients Protect practitioners

Goals of Practice Guidelines   Guidelines are “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.” - Field MJ, Lohr MU, eds: Clinical Practice Guidelines: Directions for a New Program. National Academy Press, 1990

When Guidelines might be of use…  Infrequent events with poor outcomes  Frequent clinical events with diagnostic uncertainty  Frequent clinical events with therapeutic uncertainty

When Guidelines might be of use…  Infrequent events with poor outcomes  ACLS- cardiac pathways -pro-con  Spinal cord and steroid use….

When Guidelines might be of use…  Infrequent events with poor outcomes  Spinal cord and steroid use…. “I believe steroids are harmful and without benefit, yet I give them when indicated to avoid litigation.” - anonymous

When Guidelines might be of use…  Frequent clinical events with diagnostic uncertainty -Ottawa ankle rules -Ottawa ankle rules -chest pain -chest pain -pulmonary embolism -pulmonary embolism -minor head injury -minor head injury

When Guidelines might be of use…  Frequent clinical events with therapeutic uncertainty -community acquired pneumonia -community acquired pneumonia -deep venous thrombosis -deep venous thrombosis -headache -headache

Guideline chaos…example  University of Virginia clinical guidelines -1/3 out of date -1/3 infrequently used -1/3 used frequently by many providers…

Guideline chaos….  University of Virginia 2002 Plan- Scrap most of them….  Focus on 5 frequent scenarios… Pain, DVT, CAP, Detox, vent care  Multidisciplinary / cross-service input  Informatics  Feedback

Are clinicians using guidelines?  Yes and no… High risk scenarios… High risk scenarios… Unclear clinical situations…. Unclear clinical situations….

Are clinicians using guidelines? -modified from Bleck TP: BMJ 321 (7255):239 Alternative evidence rating scale ;) Class 0: Things I believe Class 0a: Things I believe despite the data Class 1: Randomized controlled clinical trials that agree with what I believe… Class 2: Other prospectively collected data Class 3: Expert opinion Class 4: Other data that disagrees with me Class 5: What you believe that I don’t

Why not ? “…specific clinical circumstances” -may not apply at individual level -not generalizable Wears RL. Headaches from Clinical Guidelines Ann Emerg Med. 2002; 39:334

Headaches from Clinical Guidelines Wears RL Ann Emerg Med. 2002; 39:334  Commenting on report that emergency physicians do not follow guidelines for treating benign headaches (Vinson DR: Ann Emerg Med 2002;39:215) -lack of awareness and familiarity -specialty body formulation

Headaches from Clinical Guidelines Wears RL Ann Emerg Med. 2002; 39:334 -inertia -current practice acceptable, effective -not a problem that needs solving…. “Change will occur rapidly if changing solves a problem for the clinician.”

 Element of diagnostic uncertainty with headaches in the ED….but the guidelines are specific for migraine…. …rational to withhold treatment in presence of diagnostic uncertainty… Headaches from Clinical Guidelines Wears RL Ann Emerg Med. 2002; 39:334

 General objection to idea of guidelines… -cookbook -art of medicine Headaches from Clinical Guidelines Wears RL Ann Emerg Med. 2002; 39:334

 3 legitimate, philosophical arguments that have not been discussed…. -Feedforward guidance -Feedforward guidance -Application of aggregate to individuals -Application of aggregate to individuals -Variation may not be bad… -Variation may not be bad… Headaches from Clinical Guidelines Wears RL Ann Emerg Med. 2002; 39:334

 What is a good strategy for success of guidelines? -Does current behavior need to be changed? -What is the problem with decision- making? -How to effect change? -Didactic presentations ? Coercive? Headaches from Clinical Guidelines Wears RL Ann Emerg Med. 2002; 39:334

Questions?