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BMJ recently reported [1] that the Institute of Medicine(IOM; part of
the U.S. National Academy of Sciences) proposes that the U.S. needs “an
independent program to evaluate which diagnostic, treatment, and
prevention services work best for various patients and circumstances” ([2]
p.236). The IOM further recommends that the most pragmatic approach would
be to build upon the efforts of the IOM [2]. While there is room for
improvement in the development of clinical practice guidelines, there are
major concerns about allowing the IOM to have sole influence on policy
regarding treatment, especially if the views of the IOM do not reflect the
views of the clinical and research community.
To illustrate the nature of this problem, earlier this year the IOM
prepared a report on the treatment of posttraumatic stress disorder (PTSD)
[3]. This report reached very different conclusions about “what works”
for the treatment of PTSD compared to recent literature reviews, meta-
analyses, and evidence-based clinical practice guidelines. According to
the IOM’s report, there was sufficient evidence only to conclude that
exposure therapies were efficacious, and inadequate evidence to determine
the efficacy of other treatments, including medications widely used in the
treatment of PTSD such as the selective serotonin reuptake inhibitors
(SSRIs). The working group for this IOM report was largely composed of non
-experts in the area of PTSD [see ref. 3]. In contrast, other, expert-
based clinical practice guidelines [e.g., 4-7] generally agree that there
are several empirically-supported treatments for PTSD, including SSRIs and
psychotherapies aside from exposure therapy.
Given the discrepancy between the IOM and other review panels about
the efficacy of PTSD treatments, one wonders whether the IOM would produce
discrepant findings with other expert panels about the treatment of other
disorders. At this juncture it would seem premature and inappropriate to
allow a single body such as the IOM to pass judgment on treatment
efficacy. Clearly, it is important that the views of other groups, such as
review panels composed of researchers and clinicians with expertise in a
given disorder, be considered when shaping health care policy, especially
if the views of the experts differ markedly from the views espoused by the
IOM.
References
1. Hopkins Tanne, J. (2008). US Institute of Medicine recommends new
body to assess which treatments work in health care. British Medical
Journal, 336, 236.
2. Institute of Medicine (IOM) Committee on Reviewing Evidence to
Identify Highly Effective Clinical Services. (2008). J. Eden, B. Wheatley,
B. McNeil, & H. Sox (Eds). Knowing what works in health care: A
roadmap for the nation. Washington, DC: The National Academies Press.
3. Institute of Medicine (IOM). (2007). Treatment of Posttraumatic
Stress Disorder: An Assessment of the Evidence. Washington, DC: The
National Academies Press.
4. American Psychiatric Association (2004). Practice guidelines for
the treatment of patients with acute stress disorder and posttraumatic
stress disorder. Washington, DC: Author.
5. Canadian Psychiatric Association (2006). Clinical practice
guidelines: Management of anxiety disorders. The Canadian Journal of
Psychiatry, 51, Suppl 2, 57S-64S.
6. Department of Veterans Affairs & Department of Defense.
(2004). VAa/DoD clinical practice guideline for the management of post-
traumatic stress. Washington, DC: The management of post-traumatic stress
working group.
7. National Institute for Clinical Excellence (2005). Clinical
Guideline 26: Post-traumatic stress disorder (PTSD): Tthe management of
PTSD in adults and children in primary and secondary care. London, UK:
National Institute for Clinical Excellence.
The future of “what works in health care”
To the Editor:
BMJ recently reported [1] that the Institute of Medicine(IOM; part of
the U.S. National Academy of Sciences) proposes that the U.S. needs “an
independent program to evaluate which diagnostic, treatment, and
prevention services work best for various patients and circumstances” ([2]
p.236). The IOM further recommends that the most pragmatic approach would
be to build upon the efforts of the IOM [2]. While there is room for
improvement in the development of clinical practice guidelines, there are
major concerns about allowing the IOM to have sole influence on policy
regarding treatment, especially if the views of the IOM do not reflect the
views of the clinical and research community.
To illustrate the nature of this problem, earlier this year the IOM
prepared a report on the treatment of posttraumatic stress disorder (PTSD)
[3]. This report reached very different conclusions about “what works”
for the treatment of PTSD compared to recent literature reviews, meta-
analyses, and evidence-based clinical practice guidelines. According to
the IOM’s report, there was sufficient evidence only to conclude that
exposure therapies were efficacious, and inadequate evidence to determine
the efficacy of other treatments, including medications widely used in the
treatment of PTSD such as the selective serotonin reuptake inhibitors
(SSRIs). The working group for this IOM report was largely composed of non
-experts in the area of PTSD [see ref. 3]. In contrast, other, expert-
based clinical practice guidelines [e.g., 4-7] generally agree that there
are several empirically-supported treatments for PTSD, including SSRIs and
psychotherapies aside from exposure therapy.
Given the discrepancy between the IOM and other review panels about
the efficacy of PTSD treatments, one wonders whether the IOM would produce
discrepant findings with other expert panels about the treatment of other
disorders. At this juncture it would seem premature and inappropriate to
allow a single body such as the IOM to pass judgment on treatment
efficacy. Clearly, it is important that the views of other groups, such as
review panels composed of researchers and clinicians with expertise in a
given disorder, be considered when shaping health care policy, especially
if the views of the experts differ markedly from the views espoused by the
IOM.
References
1. Hopkins Tanne, J. (2008). US Institute of Medicine recommends new
body to assess which treatments work in health care. British Medical
Journal, 336, 236.
2. Institute of Medicine (IOM) Committee on Reviewing Evidence to
Identify Highly Effective Clinical Services. (2008). J. Eden, B. Wheatley,
B. McNeil, & H. Sox (Eds). Knowing what works in health care: A
roadmap for the nation. Washington, DC: The National Academies Press.
3. Institute of Medicine (IOM). (2007). Treatment of Posttraumatic
Stress Disorder: An Assessment of the Evidence. Washington, DC: The
National Academies Press.
4. American Psychiatric Association (2004). Practice guidelines for
the treatment of patients with acute stress disorder and posttraumatic
stress disorder. Washington, DC: Author.
5. Canadian Psychiatric Association (2006). Clinical practice
guidelines: Management of anxiety disorders. The Canadian Journal of
Psychiatry, 51, Suppl 2, 57S-64S.
6. Department of Veterans Affairs & Department of Defense.
(2004). VAa/DoD clinical practice guideline for the management of post-
traumatic stress. Washington, DC: The management of post-traumatic stress
working group.
7. National Institute for Clinical Excellence (2005). Clinical
Guideline 26: Post-traumatic stress disorder (PTSD): Tthe management of
PTSD in adults and children in primary and secondary care. London, UK:
National Institute for Clinical Excellence.
Competing interests:
None declared
Competing interests: No competing interests