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Feature Clinical guidelines

Ensuring the integrity of clinical practice guidelines: a tool for protecting patients

BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f5535 (Published 17 September 2013) Cite this as: BMJ 2013;347:f5535

Rapid Response:

Re: Ensuring the integrity of clinical practice guidelines: a tool for protecting patients

Dear Editor,
I challenge the premise of this endeavor to fix the process of creating guidelines so that they are always or even most often reliable. The premise, although not explicitly stated, was that it is possible to formulate a methodology for impaneling medical experts to create evidence based clinical practice guidelines with integrity that should be followed by all physicians, funded by all public and private medical insurers, available to all patients, and used as the basis for deciding malpractice litigation by all courts. The authors listed numerous examples about the biases and financial conflicts of interest that have influenced the drafting of guidelines to the detriment of patients. However, they mentioned no alternative to the status quo of all powerful national guidelines issued by National Institutes for Health and Clinical Excellence in the UK and, in the USA, special interest groups like the American Heart Association/American Stroke Association now that the National Institutes of Health is getting out of the guideline business.

As everyone knows, national clinical practice guidelines create revenue streams from patients and public and private insurance companies to practitioners, drug companies, other medical providers, and medical journals. Clinical practice guidelines protect physicians from malpractice suits when guideline compliant interventions kill or disable patients. Guidelines may lead physicians to provide tests or treatments that may be against their better judgment. Accept it; special interest organizations will continue to publish guidelines that benefit the financial interests of their members or supporters, often to the detriment of patient care. The authors propose an elaborate and well researched system for avoiding biases in clinical practice guidelines. If all the special interests in the gravy train of money from clinical practice guidelines suddenly comply with these recommendations, the medical establishment would stand to lose tens or hundreds of billions of dollars per year. This won’t happen. An alternative plan is needed.

I’m not saying that the answer is to abandon guidelines and let every physician do what he/she thinks is best. However, consider that clinical practice guidelines should be decentralized so every trust in the UK and, in the USA, accountable care organization should decide for each clinical situation whether to follow the default national guidelines or to establish an alternative practice guideline. Patients could choose trusts in the UK or ACOs or other providers in the USA in part due to whether the clinical practice guidelines that they care about are or are not in conformity with the default national guidelines. With competing trusts or ACOs allowed to have differing clinical practice guidelines, physicians could choose to work for a trust or ACO with guidelines that were most compatible with their medical philosophy. By decentralizing the authority to institute and enforce clinical practice guidelines, a large number of patients from competing trusts or ACOs following different guidelines but receiving similar insurance reimbursement can be compared in term of clinical outcomes and cost effectiveness.

Trying to fix the methodology for producing national clinical guidelines will not mend the broken healthcare system. Instead, allow a functioning medical marketplace to be created with competition for patients based on differing guidelines. This will disrupt the entrenched corruption in the current system by incentivizing good clinical outcomes and the avoidance of waste while enabling evidence based medicine researchers to compare clinical outcomes related to competing guidelines, a potentially more powerful tool than randomized controlled clinical trials.

Competing interests: No competing interests

24 September 2013
David K. Cundiff
Physician
Independent EBM researcher
333 Orizaba Ave. Long Beach, CA 90814