The Promises And Pitfalls Of Evidence-Based Medicine (original) (raw)

Evidence-Based Guidelines--An Introduction

Hematology, 2008

Recommendations in the form of clinical practice guidelines are increasingly common. Clinical guidelines are systematically developed statements designed to help administrators, practitioners and patients make decisions about appropriate health care for specific circumstances. In North America, guidelines developed by professional societies, government panels and cooperative groups are frequently used to measure quality, to allocate resources and to determine how health care dollars are spent. For clinicians, guidelines provide a summary of the relevant medical literature and offer assistance in deciding which diagnostic tests to order, which treatments to use for specific conditions, when to discharge patients from the hospital, and many other aspects of clinical practice.

Clinical Guidelines: Where Next?

International Journal for Quality in Health Care, 1997

In a growing Dumber of countries, guidelines are playing an increasingly important role in assuring the quality of care. Their validity-depends on a systematic development process and explicit links between recommendations and underlying evidence. Their role in aiding clinical decision making depends on their developers identifying the key decisions and their consequences; gathering the relevant evidence on the risks and costs of alternative decisions; and presenting the appropriate evidence to make each key decision hi a simple and accessible format, possibly electronic Decision analysis is a potentially powerful tool for clarifying clinical decisions and involving patients directly in the process but its routine use hi guidelines is complex and has yet to be fully evaluated. Duplication of guidelines can be avoided by appraising and adapting existing guidelines hi local contexts. There is very Httfc evidence available about the Impact of guidelines on the doctor-patient relationship. They might have a potentially deleterious effect, but the combination of explicit guidelines eliciting patient preferences and Information technology might redress the balance by increasing the role of patients themselves.

The Need to Systematically Evaluate Clinical Practice Guidelines

Clinical practice guidelines abound. The recommendations contained in these guidelines are used not only to make decisions about the care of individual patients but also as practice standards to rate physician " quality. " Physicians' confidence in guidelines is based on the supposition that there is a rigorous, objective process for developing recommendations based on the best available evidence. Though voluntary standards for the development of guidelines exist, the process of guideline development is unregulated and the quality of many guidelines is low. In addition, the few tools available to assess the quality of guidelines are time consuming and designed for researchers, not clinicians. Few guidelines are evaluated, either before or after their dissemination , for their impact on patient outcomes. Just as with pharmaceuticals and other products that can affect patients for better or worse, perhaps it is time to develop more standardized ways to evaluate the development and dissemination of clinical practice guidelines to ensure a similar balance between risk and benefit. (J Am Board Fam Med 2016;29:644 – 648.)

Guideline to Guidelines. Implementation of scientific evidence into clinical guidelines

Research Square (Research Square), 2023

Background: The knowledge and help provided by the medical guidelines are essential to make informed clinical decisions. However, there are no systematic methods to assess the e cacy of guidelines, i.e., how much contribution they provide to informed decisions in various health conditions. Methods: A mathematical analysis was developed to assess the e cacy of guidelines. As an example, the "2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease" (GL-SCE) was analysed/assessed. The analysis was conducted on the Classes of Recommendations (CLASS) and the Levels of Evidence (LEVEL). LEVEL areas under CLASS were calculated to form a Certainty Index (CI:-1 to+1). Results: The frequency of CLASS I ('to do') and CLASS III ('not to do') was relatively high in GL-SCE. Yet, the most frequent LEVEL was C, indicating a low quality of scienti c evidence. The GL-SCE showed a relatively high CI (+0.57), 78.4% Certainty and 21.6% Uncertainty. Conclusions: GL-SCE provides a substantial help to decision-making through the recommendations, but the supporting evidence in most CLASSes has low quality, which is well-re ected in the developed Certainty Index identifying issues that should be clari ed and investigated in future studies. We propose that the developed mathematical analysis should be used as a Guideline to Guidelines to assess their e cacy and support their implementation in clinical practice thus providing a 'quality control'. Contribution to the literature This study provides a mathematical analysis to objectively measure the help/contribution to medical decision-making provided by any medical Guidelines; this analysis allows a better understanding of the classes of recommendations and the levels of scienti c evidence. The higher level of scienti c evidence and/or clinical signi cance of lower evidence may be increased by conducting new experimental and clinical studies on uncertain issues revealed with this analysis on the Guidelines; thus, the e cacy of clinical decision-making can be increased. The outlined mathematical analysis provides a 'quality control', and as such, it can be used as a Guideline for assessing the e cacy of the Guidelines. Background Medical societies publish several guidelines to help medical professionals to make decisions in certain disease conditions. Recently by analysing four ESC GLs for CVDs, we revealed that the contribution provided by them to make a decision is uneven, based on the Certainty/Uncertainty ratio [1]. Indeed, the GLs' contribution to decision-making can vary based on the Levels of Evidence (LEVEL) and Classes of Recommendations (CLASS). It is obvious that in the recommendations of Class I (recommended/indicated) 'to do' and Class III (not recommended) 'not to do', the decision is clear

The Proliferation of Clinical Practice Guidelines: Professional Development or Medicine-by-Numbers?

The Journal of the American Board of Family Medicine, 2005

In a medical milieu of extensive research, rapidly proliferating information, and a multitude of potential therapies, there has been an escalating trend toward the development and dissemination of clinical practice guidelines outlining investigative and management protocols for clinical problems. There are substantial benefits to providing educational directives and securing widespread adherence to specific clinical practice standards as a means to ensure a consistent acceptable standard-of-care. On the other hand, the increasing tendency to regard authoritative documents as dogma may hinder ongoing medical progress and facilitate the adoption of a "follow-the-recipe" approach to medical practice. A healthy tension between physician autonomy and recommended practice guidelines needs to be cultivated in primary care as well as in specialty clinical practice. In response to increasing concern surrounding issues of impartiality and commercial influence on the development of practice directives, a mechanism designed to assure integrity and credibility of guidelines is required. (J Am Board Fam Pract 2005;18: 419 -25.)

Evidence vs Consensus in Clinical Practice Guidelines

JAMA, 2019

Clinical practice guidelines have become increasingly prominent in clinical medicine over the last 4 decades, and represent one of the most important tools for potentially improving clinical decision-making and, in turn, potentially improving patients' outcomes. 1

A view into clinical practice guidelines: who uses them, who doesn’t and possibly, why

Qualitative Research in Medicine and Healthcare, 2017

Medical professional societies each develop specific clinical practice guidelines (CPGs). Based on the best available evidence, CPGs are intended to control variability and optimize quality of care in clinical practice. Yet, healthcare providers often do not accept or adhere to guidelines, but their reasons are not fully understood. When providers opt to choose not to follow CPGs, unfavorable patient outcomes including unequal access to treatment become negative consequences. In this small qualitative study, we will explore what causes non-adherence to CPGs and what changes have been made to CPGs from when physicians completed their medical residencies to the present. We interviewed physicians from a variety of medical specialties to assess how these changes may influence guideline adherence as well as the consequences of not following them. We found that guidelines may not be followed in cases where patients have comorbidities that are not described in the guidelines or when physic...