Are guidelines for monitoring chronic disease in primary care evidence based?BMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l2319 (Published 13 June 2019) Cite this as: BMJ 2019;365:l2319
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Over a decade ago, I visited a number of publishers of clinical guideline ressources for GPs and suggested that the various primary care IT providers could develop an AI 'engine' that would interact with the data entered by the doctor during the consultation (free-text/Reed Code etc) and be 'coupled up' to the NICE Guidelines on specific conditions.
The AI would offer prompts and direct guidance thereby effectively delivering, in interactive form, real-time assistance that would bring Fig1 (and other relevant guidelines and evidence) into every relevant consultation.
Since GPs are even busier now and NICE Guidelines are essentially regarded as protocols based on "expert opinion", with "robust evidence for optimal monitoring strategies and testing intervals..lacking", might I suggest that the experts and relevant primary care professional bodies get their heads together and develop a system that will help busy doctors and concerned patients to address (not just be "aware of") the "uncertainities when making shared decisions about chronic disease monitoring". It is simply no good coming up with worthy aspirations; what front-line practitioners need are specific actions and resources that will enable every consultation to be safe, sound and supportive for both patient and doctor.
Competing interests: No competing interests
Elwenspoek et al review the evidence base behind the current UK guidelines for the monitoring of diabetes and hypertension in primary care. They conclude - rightly - that the majority of current guidelines are based upon expert opinion and consensus, rather than 'hard' or published evidence. They argue that unnecessary testing in primary care can lead to false positive and negative results, increased workload, and increased costs. They suggest that current guidelines should be used where there is robust evidence to support them, but that the majority of guidelines should not be uncritically adopted; instead, that they should inform discussion of the related issues with patients, taking into account patient values and preferences.
While the above is logical and represents ideal practice, the reality is that such an approach is impractical on several levels. Primary care providers are chronically overworked and lack the resources to devote to mass education programmes of this nature, while most patients are not sufficiently informed or motivated to engage in such decisions. If experts in the field do not know the ideal frequency of follow-up, how can even the most well-informed patient?
Guidelines are not proscriptive. However, by specifying a baseline level of care, they provide reassurance to patients that they are receiving safe follow-up, and reassurance to physicians that their practice is in line with accepted norms. Non-adherence to a recommended follow-up regimen has potential risks for both parties. In particular, it should be recognised that failure to follow accepted practice may place the physician at increased risk of medicolegal challenge in the event of complications.
Guidelines are not perfect and are often based upon imperfect evidence, but the reality is that they underpin safe medical practice, are usually highly cost-effective, and should be ignored at both the patient's and physician's peril.
Competing interests: I am Chair of the Standards Committee of the British Transplantation Society and have co-authored and edited numerous national guidelines in this field, and have contributed to national guidelines for the monitoring of diabetes and chronic kidney disease. I also undertake medicolegal work in these areas.