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Report casts doubt on medical guidelines

By Frederik Joelving

NEW YORK (Reuters Health) - Many medical guidelines don't stick to quality standards designed to make them trustworthy, and the situation hasn't improved over the past two decades, researchers have found.

"Everybody everywhere is developing guidelines and there is no real quality control," said Dr. Philip A. Mackowiak, who led the new work. "There is no good oversight of who actually develops the guidelines or what criteria need to be met in order for them to be published."

Guidelines help doctors keep up with the latest developments in their fields and are widely perceived as a recipe for good patient care. Insurers also use them to make payment decisions and they can sway court decisions, said Mackowiak, of VA Maryland Health Care System in Baltimore.

But studies have found that guidelines are often based on opinion and weak data, instead of high-quality evidence from clinical trials. And the new findings show wide variation in how closely they follow quality standards set out by the Institute of Medicine, a prestigious U.S. organization that is part of the National Academy of Sciences.

"If they are not quality documents, all these purposes they are supposed to serve become horribly flawed," Mackowiak, also at the University of Maryland School of Medicine, told Reuters Health.

His team reviewed 130 randomly selected medical guidelines published by the National Guideline Clearinghouse and benchmarked them against 18 quality standards.

Fewer than half of the guidelines met 10 or more of the standards, which include things like reporting how panel members are chosen, how the evidence is collected and describing potential side effects of recommended treatments.

Their findings were published by the Archives of Internal Medicine.

FREQUENT CONFLICTS OF INTEREST

The IOM also recommends that panel chairs and co-chairs be free of conflicts of interest, which in theory might warp their judgments.

Yet fewer than half of the guidelines stated whether their members had conflicts of interest. Among those that did, 71 percent of the chairs and 91 percent of the co-chairs had conflicts - and for U.S. government agencies and subspecialty societies, the numbers were even higher.

Mackowiak worried that conflicting financial interests may create tension between what's good for the patient and what's good for business. For a gastroenterologist urging colonoscopies, for instance, "you are basically writing a guideline that makes patients come to see you regularly," he said.

The Institute of Medicine's standards were not published until 2011, and Mackowiak acknowledged that the experts who developed the guidelines reviewed by his team would not have been able to see them. But he added that similar standards have been published before and that they were basic enough that they should have been followed.

The researchers also compared their findings with results from a similar study from the 1990s done by Dr. Terrence Shaneyfelt and colleagues. They found "very little if any improvement" since then.

Getting medical advice can have far-reaching consequences for public health.

For example, one recommendation from specialists in infectious diseases urged doctors to treat suspected pneumonia with antibiotics right away. But it ended up fueling overtreatment with no apparent benefits, because many cases are not caused by bacteria. Treating those cases with antibiotics is likely to breed drug-resistant bacteria and expose patients unnecessarily to side effects.

In a commentary published with the new findings, Shaneyfelt, of the Department of Veterans Affairs and the University of Alabama at Birmingham, says that until the situation is improved, guidelines are not trustworthy.

"I am not optimistic that much will improve" over the next decade, he writes. "No one seems interested in curtailing the out-of-control guideline industry."

Mackowiak said medical journals and organizations that publish guidelines should start requiring that they meet the Institute of Medicine's standards.

"They should be exercising greater editorial control," he said.

SOURCE: http://bit.ly/RdJrNC Archives of Internal Medicine, online October 23, 2012.

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