EDITORIAL * EDITORIAL
Clinical
practice guidelines
Anne Carter, MD, MHSc, FRCPC he article by Stiell and associates in this issue (starting on page 1671) raises a number of questions: What are clinical practice guidelines? Why do we need them? How should they be developed? Who should develop them? What are clinical practice guidelines? In 1990 the Institute of Medicine in the United States defined practice guidelines as "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances."' This definition has been generally accepted. The term clinical is used when referring to guidelines that concern clinical decisions (rather than ethical, legal, educational or other decisions that physicians make while practising medicine). Guidelines are not rules or standards; they are helpful, flexible syntheses of all the available, relevant, good-quality information applicable to a particular clinical situation that the clinician and patient need to make a good decision. Why do we need guidelines? Medicine is undergoing a revolution. The assumption that the physician knew instinctively what to do on the basis of training, continuing education and clinical judgement (the art of medicine) has been challenged. This challenge is based on some compelling observations that have recently been summarized: there is tremendous variability in care provided for similar patients and conditions, physicians have widely varying perceptions of the outcomes of care, and some modalities of care have been found to have little (or no)
single physician cannot form accurate impressions of efficacy on the basis of personal observation. Instead, complex studies must be done to determine efficacy.3 Finding and evaluating these studies has become a full-time job, even for those who limit their practice to a tiny fraction of the scope of medicine. The necessary complex studies have not all been done, because research efforts have not been able to keep up with the pace of new developments, their use in multiple populations and circumstances, and their costs and outcomes. Even if studies are available and the clinician has the time to assess and incorporate them into practice, many situations are so complex that it takes a computer to combine all the probabilities of all the decision points to come up with an answer. Our ability to unveil the mysteries of health and disease and to develop ingenious interventions has far outstripped the ability of the unassisted physician to use all the information. Add to this the fact that the costs of medical care are beginning to overtake our society's ability to remain competitive in the world marketplace. All of the costs of care are eventually paid by real people who then do not have that money to spend on other things. Governments are demanding that these costs be controlled. The best way to start to control costs is to make sure that all the care we give is effective. Clinical practice guidelines are at least part of the solution to these problems. They are, in effect, what the clinician would create personally if he or she had the time and resources to accomplish a full evaluation alone. The art of medicine remains efficacy.2 There is no question that the co-mplexity of a crucial ingredient in the practice of medicine medical decisions is growing rapidly. As chronic with guidelines. Guidelines summarize collective diseases have come to predominate, outcomes are no experience as determined scientifically. The clinician longer as obvious, immediate or dramatic as they must integrate this into the unique situation of each were when acute disorders were common, and a patient as determined from the history and physical T
Dr. Carter is associate director, health care and promotion, at the CMA.
Reprint requests to: Dr. Anne Carter, CMA House, 1867 Alta Vista Dr., Ottawa, ON KIG 3Y6 DECEMBER 1, 1992
CAN MED ASSOC J 1992; 147 (1 1)
1649
examination. The steps of eliciting the individual characteristics and integrating them into the collective experience represent a challenge worthy of the term "art." This is not cookbook medicine. How should clinical practice guidelines be developed? They should be developed with the use of scientifically sound methods. No one physician alone, even a trauma specialist, can determine accurately from personal experience the best way to identify patients with an ankle injury who will benefit from having radiography. The result, as clearly shown by Stiell and associates, is that x-ray films are taken of almost every injured ankle even though physicians know that few of the films will contribute to patient care. The experience of many physicians at several hospitals can be accumulated over time, however, and used to accurately determine the valid indications for ankle radiography and thus a guideline. Stiell and associates' work is an example of physicians analysing and using routinely collected clinical data to improve clinical management. For many years our health information systems have been aimed at assisting the general management of the health care system. It is important that physicians begin to routinely use these systems to solve clinical problems. Resourceful use of routine data can often obviate the need for more costly and time-consuming research such as randomized controlled trials. If we are to have any hope of quickly filling all the holes in our knowledge about the outcomes of clinical care, we must use our time and resources wisely. Who should develop clinical practice guidelines? Practice guidelines have the potential to greatly assist physicians, patients and the health care system only if they are done right: they must be valid and useful in real clinical situations. Physicians must be
1650
CAN MED ASSOC J 1992; 147 (1 1)
intimately involved in their creation. As the guidelines movement gets under way, the medical profession must seize the opportunity to make sure that guidelines are properly crafted. To this end, the CMA has formed a partnership with other national medical organizations (the Royal College of Physicians and Surgeons of Canada, the College of Family Physicians of Canada, the Federation of Medical Licensing Authorities of Canada and the Association of Canadian Medical Colleges) to facilitate and coordinate the development of clinical practice guidelines in Canada. The purpose of the partnership is to prevent duplication of effort, to direct efforts to the highest-quality guidelines in the highest-need areas and to ensure that the guidelines developed are disseminated and found useful by clinicians. The guidelines can then contribute to improved quality of care and health outcomes for Canadians. They will almost certainly aid physicians in providing care at a lower cost by helping to identify and eliminate ineffective practices, as Stiell and associates have done.
References 1. Field MJ, Lohr KN (eds): Clinical Practice Guidelines: Directions for a New Program, Committee to Advise the Public Health Service on Clinical Practice Guidelines, Institute of Medicine, US Dept of Health and Human Services, Natl Acad Pr, Washington, 1990: 38 2. Idem: Guidelines for Clinical Practice: from Development to Use, Committee on Clinical Practice Guidelines, Division of Health Care Services, Institute of Medicine, Natl Acad Pr, Washington, 1992: 37-38
3. Naylor CD: Two cheers for meta-analysis: problems and opportunities in aggregating results of clinical trials. Can Med Assoc J 1988; 138: 891-895
LE ler DECEMBRE 1992
Clinical
practice guidelines
Anne Carter, MD, MHSc, FRCPC he article by Stiell and associates in this issue (starting on page 1671) raises a number of questions: What are clinical practice guidelines? Why do we need them? How should they be developed? Who should develop them? What are clinical practice guidelines? In 1990 the Institute of Medicine in the United States defined practice guidelines as "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances."' This definition has been generally accepted. The term clinical is used when referring to guidelines that concern clinical decisions (rather than ethical, legal, educational or other decisions that physicians make while practising medicine). Guidelines are not rules or standards; they are helpful, flexible syntheses of all the available, relevant, good-quality information applicable to a particular clinical situation that the clinician and patient need to make a good decision. Why do we need guidelines? Medicine is undergoing a revolution. The assumption that the physician knew instinctively what to do on the basis of training, continuing education and clinical judgement (the art of medicine) has been challenged. This challenge is based on some compelling observations that have recently been summarized: there is tremendous variability in care provided for similar patients and conditions, physicians have widely varying perceptions of the outcomes of care, and some modalities of care have been found to have little (or no)
single physician cannot form accurate impressions of efficacy on the basis of personal observation. Instead, complex studies must be done to determine efficacy.3 Finding and evaluating these studies has become a full-time job, even for those who limit their practice to a tiny fraction of the scope of medicine. The necessary complex studies have not all been done, because research efforts have not been able to keep up with the pace of new developments, their use in multiple populations and circumstances, and their costs and outcomes. Even if studies are available and the clinician has the time to assess and incorporate them into practice, many situations are so complex that it takes a computer to combine all the probabilities of all the decision points to come up with an answer. Our ability to unveil the mysteries of health and disease and to develop ingenious interventions has far outstripped the ability of the unassisted physician to use all the information. Add to this the fact that the costs of medical care are beginning to overtake our society's ability to remain competitive in the world marketplace. All of the costs of care are eventually paid by real people who then do not have that money to spend on other things. Governments are demanding that these costs be controlled. The best way to start to control costs is to make sure that all the care we give is effective. Clinical practice guidelines are at least part of the solution to these problems. They are, in effect, what the clinician would create personally if he or she had the time and resources to accomplish a full evaluation alone. The art of medicine remains efficacy.2 There is no question that the co-mplexity of a crucial ingredient in the practice of medicine medical decisions is growing rapidly. As chronic with guidelines. Guidelines summarize collective diseases have come to predominate, outcomes are no experience as determined scientifically. The clinician longer as obvious, immediate or dramatic as they must integrate this into the unique situation of each were when acute disorders were common, and a patient as determined from the history and physical T
Dr. Carter is associate director, health care and promotion, at the CMA.
Reprint requests to: Dr. Anne Carter, CMA House, 1867 Alta Vista Dr., Ottawa, ON KIG 3Y6 DECEMBER 1, 1992
CAN MED ASSOC J 1992; 147 (1 1)
1649
examination. The steps of eliciting the individual characteristics and integrating them into the collective experience represent a challenge worthy of the term "art." This is not cookbook medicine. How should clinical practice guidelines be developed? They should be developed with the use of scientifically sound methods. No one physician alone, even a trauma specialist, can determine accurately from personal experience the best way to identify patients with an ankle injury who will benefit from having radiography. The result, as clearly shown by Stiell and associates, is that x-ray films are taken of almost every injured ankle even though physicians know that few of the films will contribute to patient care. The experience of many physicians at several hospitals can be accumulated over time, however, and used to accurately determine the valid indications for ankle radiography and thus a guideline. Stiell and associates' work is an example of physicians analysing and using routinely collected clinical data to improve clinical management. For many years our health information systems have been aimed at assisting the general management of the health care system. It is important that physicians begin to routinely use these systems to solve clinical problems. Resourceful use of routine data can often obviate the need for more costly and time-consuming research such as randomized controlled trials. If we are to have any hope of quickly filling all the holes in our knowledge about the outcomes of clinical care, we must use our time and resources wisely. Who should develop clinical practice guidelines? Practice guidelines have the potential to greatly assist physicians, patients and the health care system only if they are done right: they must be valid and useful in real clinical situations. Physicians must be
1650
CAN MED ASSOC J 1992; 147 (1 1)
intimately involved in their creation. As the guidelines movement gets under way, the medical profession must seize the opportunity to make sure that guidelines are properly crafted. To this end, the CMA has formed a partnership with other national medical organizations (the Royal College of Physicians and Surgeons of Canada, the College of Family Physicians of Canada, the Federation of Medical Licensing Authorities of Canada and the Association of Canadian Medical Colleges) to facilitate and coordinate the development of clinical practice guidelines in Canada. The purpose of the partnership is to prevent duplication of effort, to direct efforts to the highest-quality guidelines in the highest-need areas and to ensure that the guidelines developed are disseminated and found useful by clinicians. The guidelines can then contribute to improved quality of care and health outcomes for Canadians. They will almost certainly aid physicians in providing care at a lower cost by helping to identify and eliminate ineffective practices, as Stiell and associates have done.
References 1. Field MJ, Lohr KN (eds): Clinical Practice Guidelines: Directions for a New Program, Committee to Advise the Public Health Service on Clinical Practice Guidelines, Institute of Medicine, US Dept of Health and Human Services, Natl Acad Pr, Washington, 1990: 38 2. Idem: Guidelines for Clinical Practice: from Development to Use, Committee on Clinical Practice Guidelines, Division of Health Care Services, Institute of Medicine, Natl Acad Pr, Washington, 1992: 37-38
3. Naylor CD: Two cheers for meta-analysis: problems and opportunities in aggregating results of clinical trials. Can Med Assoc J 1988; 138: 891-895
LE ler DECEMBRE 1992
