GUIDELINES GALORE!
2
M. Saleem Seyal, MD, FACP, FACC
013 undoubtedly was the
release year of a plethora
of medical guidelines of all
stripes. The sheer number of guidelines about disease states and other
related issues and situations has
been mind-boggling. The practice
guidelines, which are summaries
of recommendations culled and
synthesized from exhaustive reviews of randomized controlled trials (RCTs), are produced by the panelists and
writing committees of various professional organizations,
medical specialty societies, public or private entities,
some government agencies and health care organizations
or plans. The guidelines however are not gospel, are not
etched in stone and are not permanent because of the
very nature of medical knowledge which continues to
burgeon, evolve, and metamorphose at an amazingly
alarming speed. The guidelines are thus revised every few
years, updates are added, addendums inserted and old
recommendations considered obsolete are withdrawn.
The massive quest for educating practicing clinicians
continues unabated. Insurance companies now routinely
send letters always signed by a Medical Director, informing us that there may be “care gaps” in our medical
therapies for their insured patients, and politely nudge
us to change drugs according to the current guidelines.
They stress ever so gently that the information is advisory
and is not intended to replace the individualized patient
care of the health care provider.
The physician in this information age faces a veritable
tsunami of reading, as well as audiovisual material with
thousands of print medical journals and internet avenues.
There’s an avalanche of free webinars, review articles, expert opinions, guidance of all sorts, consensus statements
and immediate up-to-the- minute exhaustive reports via
audiovisual feeds about large specialty meetings here and
abroad. Just to give one example of unceasing repetition
in medical literature, I have counted over 40 review articles in various journals dealing solely with the use of
new anticoagulants in non-valvular atrial fibrillation in
the year 2013! In my humble opinion, one can stay quite
current, however, by selective and judicious reading of
appropriate recent clinical trial results and review articles,
and some well-written brief guidelines (if they exist).
Physicians are routinely bombarded with material to
read about various and sundry issues related to the practice of medicine, but guidelines in their profuse glory have
been another matter altogether. There are just way too
many guidelines to read, if you ask me! We
have been inundated with guidelines from
everywhere primarily and understandably by the specialty societies, but also by
various other entities. To deal with the
mushrooming number of guidelines, we
needed a public resource called National
Guidelines Clearinghouse (NGC), easily
accessible to anyone, that lists over 2400
evidence-based clinical practice guidelines
about “diseases” alone. NGC is administered
by the AHRQ (Agency for Healthcare Research and Quality) under the auspices of
the US Department of Health & Human
Services (USDHHS). Under the category of
“diseases,” the largest volume of guidelines
belongs to Cardiovascular Diseases, which
number close to 500….even though recent hypertension and other guidelines have not made
the list yet.
There had been widespread perplexity among
physicians and other interested parties regarding
the protracted delay of certain guidelines that
have been under development by the venerable National Heart Lung and Blood Institute
(NHLBI) for a very long time. In the middle of
2013 NHLBI announced rather unexpectedly
that they were getting out of the guidelines
business and had relegated that responsibility to other “partners” for the long-awaited
guidelines for hypertension (Joint National
Commission-J