Every week a new set of guidelines is published in medicine. They are designed to help the clinician and the patient understand what the standard of care is for a given medical condition. They are developed by leading experts around the country, reviewed, rewritten, updated and disseminated at great cost in terms of time, resources and dollars.
In spite of these efforts, guidelines are o en not being read or followed. Why is this the case? e answer is not a simple one but is worth understanding. In the past, guidelines were generated by individuals who o en had significant conflicts of interest that were not disclosed and led to bias. Now all the leading societies that develop guidelines try and minimize the inclusion of authors with significant conflicts and require all authors to disclose potential conflicts.
A second concern with guidelines was that the recommendations were based on expert consensus rather than randomized clinical trials. Many of these “expert opinions” were later proven wrong. Now leading societies like the American College of Cardiology and the American Heart Association label recommendations based on the strength and grade of data. A Class 1 recommendation has the highest strength and is based on findings of multiple well conducted trials. these are actions that should be done. A Class 2A recommendation are actions where the weight of evidence largely supports the action. A Class 2B recommendation are actions where the weight of evidence is mixed and should be considered with caution. A Class 3 recommendation are actions where the weight of evidence suggests that the action can cause harm and should not be done.
Other guideline concerns include delayed incorporation of new data, but the updating process has been improving rapidly in the digital age. Unfortunately, this has also led to multiple societies now writing guidelines on the same topics with sometimes conflicting recommendations. Add to that the FDA (Food and Drug Administration) interpretation of data, the insurance plans coverage interpretation, the health care system internal assessment and the ubiquitous public commentary on internet sites, and you have a guideline system in chaos! Both the clinician and patient are overloaded with data.
Add to this a “physician fatigue factor” of being overworked, blocked by payors through the use of prior authorization hoops, penalized by health care systems for overspending and reprimanded by patients for prescribing unaffordable drugs… and the net eff ect is many patients are no longer getting life-saving drugs that have a Class 1 indication.
As someone who practices in both the Canadian and US healthcare systems, I see much room for improvement. Patients should have aff ordable access to all drugs and devices that are a Class 1 recommendation. We need to demand that of our insurers and our legislators. However until then, it is equally important that as health care providers we make sure that we keep up with the best guidelines and off er our patients those class 1 recommendations. I have seen many wealthy individuals turn down the best therapies while other individuals with less nancial resources willing to pay at all costs for the best treatment. Our role should always be to off er best proven therapy and let the patient decide if they want to proceed. We need to continue to champion for the best interest of our patients in a world of con icting guidelines and challenging impediments to quality health care delivery.
