A welter of issues remain, around the challenge of reliably regularly producing high-quality clinical guidelines, argue two healthcare policy researchers, in the Health Affairs Blog. Writing in Health Affairs online on Aug. 5, Gilbert Benavidez, M.P.H., and Austin B. Frakt, Ph.D., dissect what they see as core policy issues, offering solutions, including sufficient, consistent federal funding for guidelines-related research, and the enforcement of “a rigorous, universal methodology for creating guidelines.”
Under the headline, “Fixing Clinical Practice Guidelines,” Benavidez, a policy analyst operating out of the Partnered Evidence-based Policy Resource Center at the Boston Veterans Affairs health care system, and Frakt, director of the Partnered Evidence-based Policy Resource Center at the Boston Veterans Affairs health care system, and an associate professor affiliated with the Boston University (BU) School of Medicine and the BU School of Public Health, write that, “Despite a historical resistance to ‘cookbook medicine,’ the early 1990s saw the proliferation of clinical guidelines in effort to improve clinical quality and control costs. The Institute of Medicine (IOM) first recommended the development of guidelines in 1990. Soon after, many professional organizations, such as the American Medical Association (AMA), began producing their own guidelines.”
Nevertheless, the researchers write, “Three decades later, we still haven’t figured out how to reliably produce high-quality guidelines, to the consternation of influential curators of medical science. There are two core issues that lead to a host of problems. First, there is a lack of centralized authority to coordinate, vet, approve, and catalog guidelines. Second, there is an absence of a universal methodology to create guidelines—every professional organization promulgating guidelines today generally decides freely which, if any, framework they will use to construct guidelines.”
As a result of the lack of consistency in the development of high-quality clinical guidelines, the authors state, “Providers must sift through a multitude of contradictory guidelines. There is a susceptibility to bias and conflicts of interest during guideline formation. And many guidelines suffer from a lack of rigor and applicability. But also as discussed below, there are specific policy steps we can take to address these issues.” Very importantly, they state, “[T]he lack of a responsible, central authority. This causes a coordination problem: The leadership vacuum gives rise to a multitude of often confusing, contradictory, and non-evidence backed guidelines.”
The researchers reference an article published in the Annals of Internal Medicine in 2011, in which Christine Laine and other colleagues wrote that “Clinical guidelines should bring order…. Yet, the development of thousands of clinical practice guidelines by hundreds of groups in dozens of countries creates its own tangle for clinicians to unravel.” “For example,” Benavidez and Frakt write, “in 2013, the National Guideline Clearinghouse included 471 guidelines for hypertension and 276 for stroke.”
Their main recommendations are two: first, “Restore funding for the Agency For Healthcare Research And Quality’s National Guideline Clearinghouse, or establish a similar central guidelines repository.” They write that “[C]entrally based coordination, cataloging, and dissemination of guidelines is imperative.” But, they note, “Unfortunately, the Trump administration recently defunded the Agency for Healthcare Research and Quality’s (AHRQ) national guidelines clearinghouse. Withdrawal from a space desperately in need of collective action is the wrong way forward. Congress should reinstate funding for the AHRQ repository, mandate through legislation that guidelines be submitted to the repository, and see that the AHRQ vets, coordinates, catalogs, and disseminates guidelines in a manner akin to that of NICE”—the United Kingdom’s National Institute for Health and Care Excellence.
“Second,” they write, “any guideline-promulgating body must use a universal methodology to facilitate the job of holding guidelines to a rigorous standard. The governing centralized body must enforce this standard, using it to assess whether guidelines meet inclusion criteria. Enforcement of a central repository would make this easy—the repository could impose a universal format required for submission and consideration, which would readily demonstrate if potential guidelines meet the required criteria. Similar to the selection criteria Australia uses, a universal methodology should include reliance on high-quality evidence, stakeholder involvement, and avoidance of bias, conflicts of interest, and contradictory information. These steps,” they conclude, “would help us make progress toward comprehensive, clear, and trustworthy guidelines that could actually address treatment variation and drive practice oward efficiency.”
