Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Too Much Medicine and Evidence-Based Guidelines – Part I


Dr. John M writes about some of the reasons we over-medicate patients. One of the reasons given is –
 

Guideline and quality measure metastases. We all want to measure the quality of health care. In this way, doctors share the same fate as teachers. Policy experts wrongly think they can measure good doctoring by electronic compliance with guidelines (call them tests). So just like teachers are, doctors are measured by tests that rarely reflect skillful practice. This can lead to mindless testing and the need to get patients on ‘evidence-based’ pills. The huge problem here is that conventional wisdom in the practice of Medicine changes. What was right in the past can turn out to be wrong now. Medicine is replete with the hubris of conventional wisdom. Overly aggressive care of diabetics and the elderly with high blood pressure are two of the most recent examples of cracks in ivory-tower thinking.[1]

 

Requiring good evidence of benefit before making a treatment part of a guideline has been dragged through the looking glass and has become too often a requirement to give a treatment to satisfy a checklist, rather than a way of protecting patients from anecdote-based treatments.

We have anecdote-based guidelines, rather than evidence-based guidelines.

Evidence-based guidelines should be discouraging treatments, rather than encouraging treatments.

The guidelines should be preventing over-prescribing by requiring good evidence for these treatments.

Look at the ACLS (Advanced Cardiac Life Support) guidelines for cardiac arrest. Chest compressions and defibrillation have good evidence of improved survival.

The so-called evidence-based guidelines include ventilations, epinephrine, vasopressin, amiodarone, lidocaine, and magnesium.[2] Then there is anything that might be used to address a potentially reversible condition in a living patient, even though these patients are not alive at the time of treatment and we do not know how that may change the behavior of the medications.

Where is the evidence of improved survival? There is none.

How did they get into the guidelines?

We accept ridiculously low standards for the evidence. This defeats the whole purpose of evidence-based medicine.

If something only has to satisfy a surrogate endpoint that someone thinks might be important to the medical condition, then are we dealing with evidence-based guidelines or wishful thinking-based guidelines that use weak and irrelevant evidence to convince us that unreasonable optimism is not really unreasonable?
 


 

Is this the fault of the evidence, of the guideline, of not understanding the guideline, or something else?

Guidelines are expected to have exceptions. Rules do not have exceptions. Often guidelines are treated as rules by people who do not understand the guideline, but only look at the algorithm, or chart, that may accompany a guideline. A lack of understanding of a guideline may not be a fault of those who created the guideline, but a fault of those misinterpreting the guideline.

For example, while beta blockers are generally good for cardiac patients, if the patient’s chest pains come from continuing to use cocaine, beta blockers are a very bad idea. Would this be a fault of the writers of the guidelines, a fault of the doctor, or both?

No drug is good for everything.

No guideline/protocol can be written to cover everything, unless it allows for encourages exceptions.

If a badly written guideline is based on evidence, that is not the fault of the evidence. The fault is with those writing the guideline.

Example from the ACLS guidelines for cardiac arrest will be described in Part II.

Footnotes:

[1] How much Medicine is enough?
Dr. John M
June 25, 2012
Article

[2] Medications for Arrest Rhythms
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 8: Adult Advanced Cardiovascular Life Support
Part 8.2: Management of Cardiac Arrest
Free Full Text from Circulation

.

Trackbacks

  1. […] from Part I of my examination of the topic of bad evidence-based guidelines raised by Dr. John M – […]

Speak Your Mind