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.


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