26 March 2018

Guidelines versus reality – a yawning chasm

Clinical Evidence Based

Experts have called for simpler and more unified clinical practice guidelines, in response to concerns that Australian children are receiving inadequate health care.

An analysis of the medical records of almost 7000 children aged 15 years and younger found that only 60% met indicators of quality care in line with clinical guidelines.

The investigators, who had previously found similar figures among Australian adults, concluded that quality of care for children “may be inadequate”.

While these studies are often met with alarm in the community and the assumption that clinicians are dropping the ball, experts say it instead highlights well-known problems with the clinical guidelines in the country.

For example, the study authors had to review an average of six guidelines per condition in order to establish their quality of care indicators, University of Sydney epidemiologist, Associate Professor Alexandra Martiniuk, noted.

“Consolidated, governed and updated guidelines per condition are needed – and importantly – the strength of the evidence underlying the guidelines needs to be provided,” she said.

Academic GP Professor Chris Del Mar, from Bond University, agreed with the need to improve guidelines, saying there were hundreds of guidelines, some of them contradictory, and many without graded evidence.

For example, guidelines issued by the colleges of GPs and urologists contradicted each other on whether to use a PSA to screen for prostate cancer, Professor Del Mar said.

To obtain the data, the study authors audited the medical records from general practices, paediatricians’ practices, hospital emergency departments and inpatient settings during 2012 and 2013.

They then compared the care recorded with indicators of quality care that were decided on by clinicians who reviewed the recommendations in 99 different international and local guidelines.

The majority of the indicators were decided based on consensus, and three in four had no official evidence grading.

Adherence varied substantially across different types of conditions. For example, adherence was highest with autism at 89%, and lowest for

tonsillitis at 44%, but was an estimated 61% for non-communicable conditions, 82% for mental health conditions, 56% for acute infections and 78% for injury.

Diabetes, head injury, as well as ADHD, anxiety, autism and depression all had adherence rates of more than 70%.

On the other hand, the study found that 41% of apparently healthy, thriving infants who presented with irritability or unexplained crying were prescribed acid-suppressing medication on their first presentation, despite a lack of evidence supporting the practice and the increased risks of infection associated with this treatment.

Professor Del Mar said the research was valuable if it encouraged clinicians to think about the quality of care they delivered and to reflect on whether they were giving evidence-based care.

But he highlighted a limitation of the study, in its use of medical records to determine the care given. What might have been measured were “inadequacies in recording information, rather than in delivering care”, he said.

For example, one quality of care indicator was doctors advising parents to return if they were worried. Professor Del Mar noted this would be something many clinicians would be likely to say, but unlikely to record.

Of concern was the potential for this kind of reporting bias to overestimate the prevalence of inadequate care and help create media hype and unjustified condemnation.

“I could see that would make clinicians defensive and irritated, and in general I think Australia does deliver good quality care,” he said.

Another issue is the assumption that care not in line with the guidelines is poor quality care.

“Guidelines are designed to guide clinicians,” Professor Del Mar said. “They are not mandatory, and there are a lot of reasons you might give different advice.”

Guidelines help clinicians make the right decision, but in conjunction with the wishes of their patient – a concept underpinning shared decision-making, he noted.

The decision to prescribe antibiotics for otitis media was one example of the limitations of this type of audit.

“Now the equipoise is that you can offer antibiotics for a kid and there is a small  –  very small – [chance] of benefit, and there is a small [risk] of harm,” he said.

In his practice, he tries to explain the evidence for both avenues of treatment and allow the parent to make the decision.

“But the approach [of this latest study] is to say one of these decisions is right and one of them is wrong,” he said.

The key to better care was to develop better guidelines that were simple and straightforward to read, and it was vital to include a grading of the strength underlying the recommendations, Professor Del Mar said.

“Then leave it to me to think about the exceptions and co-morbidities.”

JAMA; online 20 March 

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2 Comments on "Guidelines versus reality – a yawning chasm"

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Anchita Karmakar
Anchita Karmakar
7 months 18 days ago

This is why I have applied to the Federal Court to mandate the colledges and Government to form a independent health and ethics board creating standards rather then guidelines like many other professions have.

Joe Kosterich
10 months 27 days ago

Guidelines assume all patients are identical to the rarefied populations used in ivory tower trials. They are not. It is not doctors failing to follow guidelines, it is guidelines failing to be applicable to the patients of doctors.