• Clinical guidelines: Too many or too few?

    Just as there is, simultaneously, over- and under-use of health care in the US (about which, more another time), we also “enjoy” both too many and too few clinical guidelines. This passage, from page 8 of the Institute of Medicine’s Knowing What Works in Health Care explains:

    The National Guideline Clearinghouse (NGC) maintained by the Agency for Healthcare Research and Quality includes clinical guidelines from about 360 different organizations. […]

    One of the challenges inherent in having a highly decentralized, pluralistic process for developing clinical guidelines is that multiple groups will produce guidelines in the same clinical topic area. Currently, for example, the NGC contains 471 guidelines relating to the topic of hypertension and 276 guidelines related to stroke. Despite the abundance of clinical guidance for some topics, there is little clinical guidance on other important topics.

    This is, sadly, typical of the US health system. We have lots of duplication and inefficiency along side a dearth of information accompanied by tremendous need. This, despite many improvement efforts by dozens of agencies and organizations over many decades and at great cost. It’s no wonder that some throw up their hands and suggest that we just let the free market, price system sort it all out. After all, the information conveyed by prices orchestrates much of the rest of the economy beautifully, all by “invisible hand.” What could possibly go wrong?

    On the other hand, it’s rational to think nothing of the sort could work in health care, or not health care as we know it anyway. The market failures are too numerous and severe. The allure of central planning, regulation, and guidelines is completely reasonable, to a point.

    But we don’t have to be stupid about it. We don’t have to have hundreds of overlapping guidelines for disease X and zero for Y. If you’re not a clinician — and I am not — can you imagine keeping up with “the latest” when “the latest” is such a mess? If you are a clinician, I bet you can tell me some tales of woe on this front. Some already have.

    I’m not pointing fingers here. I’m not sure who to point to. It’s a collective failure or a lack of vision. Maybe it’s built into a path-dependent, policy trap we somehow set for ourselves. Maybe we made some huge mistake decades ago, and now we’re locked into a system that fails us while strongly resisting improvement. Maybe it’s just the American way, baked in the cake.

    I don’t know. Some days I just despair. Too much knowledge can be a dangerous thing, especially when it’s the same thing over and over. We’re doing it wrong. We’re doing it wrong. We’re doing it wrong.


    • I realize that any government attempt to bring order to this chaotic flowering of the free market will attract paranoid cries of “death panels”, government takeover, etc.
      However, would it be too much to designate a single “authority” for each topic… perhaps a relevant specialty society? I do understand that there will be inevitable turf wars about who should have authority for some areas where they overlap but it would really improve things to have a single source responsible for each topic. If the private sector cannot sort this out, I think the government should step in… HHS could be the referee.

      • Mark
        Does seem unlikely–

        Think of mammograms and rightful ownership for example–American College of Radiology, Amer College of Obs and Gyn (ACOG), ACP, ASCO (oncolgy)–all have a stake–both intellectually and financially–in crafting final product. HHS learned enough from PSA as well, and they wont touch this. We need a PCORI or a sanctioned USPTF to do this work. Short of that, there will be a civil war, and that is the worst possible outcome.


    • “It’s a collective failure or a lack of vision.”

      Awww, Austin… Cheer up! Maybe this will help:
      The crux of the HIV Challenge (kp.org/hivchallenge) is to challenge other private health care providers and public and community health clinics to increase the number of HIV-positive people getting effective treatment by sharing Kaiser Permanente’s toolkit of clinical best practices, provider and patient education materials, mentoring, training and health IT expertise.

      Kaiser Permanente has demonstrated excellence in HIV clinical care outcomes with:

      HIV mortality rates that are half the national average

      94 percent median treatment adherence among patients regularly in care and on antiretroviral therapy

      No disparities among its black and Latino HIV-positive patients for both mortality and medication rates, compared to a 15 percent higher rate in the United States for mortality and for medication

      89 percent of its HIV-positive patients are in HIV-specific care within 90 days, compared to 50 percent in the U.S. within one year

      69 percent of all its HIV-positive patients have maximal viral control compared to 19 percent to 35 percent nationally.
      Eventually, good guidelines will win out, as they demonstrate superior clinical outcomes. We just have to empower people to care… Yes it will take a while, but it’s going to happen. How to speed it up? I have a few ideas:
      -Publicly accessible deidentified EMR data to be analyzed at large.
      -Twitter type discussions among experts on the cutting edge explaining what works and doesn’t (this is for the realm of intuitive medicine).
      -Tying reimbursement for care of the most well understood conditions to pre-defined standards, with all deviations recorded and justified for further analysis (The importance of this is to slowly modify/improve the care of diseases which we’ve already defined appropriate care)

      It is important to realize that diseases tend to fall on a spectrum of how well we know to care for them (diagramed in “The Innovator’s Prescription figure 5.1 here: https://docs.google.com/open?id=0B7apmQpwa__qMGNjZjAxNTItNDJlZi00NGEwLTlkZGEtMjAyZTRhNjYyMmMy ). Recognize that we will have wonderful clinical guidelines for some pathologies, but others will be frustratingly absent.

      How is this system is going to be created? I think it’s going to have to be some sort of wikipedia like constantly updated discussion group controlled by verified experts (doctors, as well as patients with the disease in question). It will start by defining guidelines in smaller diseases with less resistant economic interests. As the benefits of the model become apparent, eventually patients will demand the same process in hard to change domains (orthopedics, stenting, etc.)

      The biggest obstacle is simple: Doctors convincing their patients that things are under control right now. But unsustainable medical costs are unraveling that, so I’m not too worried.

    • Here’s a different take on “guidelines”.

      This takes a futuristic view that when the guidelines/algorithms and the technology get good enough, we won’t need the “average” doctor. (Perhaps that is part of doctors resistance to guidelines.)

      He does emphasize that we will still need the “top” doctors to create the algorithms but they will get to the point (probably are at the point now) where they are better than the “average” doctor. The technology of EMR and PHR will enable better input into the algorithms and the technology of measurement devices will get better. (I can already buy Internet connected weight, blood pressure, blood sugar, respiratory flow, temperature, heart rate, ekg, O2 saturation, mobility devices … just to mention a few off the top of my head.)

      When I go to an average doctor who is not using guidelines or algorithms, I don’t know the biases of his/her personal experience and limits to their knowledge which may prevent optimal diagnosis and treatment.
      Shouldn’t everyone have access to the best doctor’s knowledge, not just an average doctor?