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Some guidelines about practice guidelines.

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Vol. 38, No. 1 1 , November 1995, pp 1533-1534
0 1995, American College of Rheumatology
Arthritis & Rheumatism
Official Journal of the American College of Rheumatology
When American College of Rheumatology
(ACR) members are surveyed, they consistently rate
the development of practice guidelines high on the list
of activities for the College. The guidelines for osteoarthritis (OA) of the hip and knee, which appear
elsewhere in this issue (1,2), continue the process
begun in 1986, when the ACR produced its first
guidelines, for reviewers of rheumatic disease care
(now in its third edition) (3). Subsequently, guidelines
for antibiotic treatment of fibromyalgia symptoms in
persons with positive serology for infection with Burrelia burgdurferi (4), monitoring liver toxicity in patients taking methotrexate (9,and assessing disease
activity in clinical trials of rheumatoid arthritis (6)
have appeared. Over the next few months, ACR
guidelines for the management of rheumatoid arthritis,
the monitoring of drug toxicity in rheumatoid arthritis,
and the evaluation of the adult patient with musculoskeletal complaints will be published. More are in the
The ACR owes a great debt to Matt Liang,
Howard Fuchs, Kent Kwoh, Rob Simms, and Robert
Shmerling, the members of the three ad hoc committees, and the reviewers. Larry Anderson and James
O’Dell deserve special recognition. Donna Cosola and
Steve Echard provided invaluable staff support. Five
guidelines and a bibliography on costs and outcomes
of rheumatologic conditions were produced in less than.
eight months at a cost of $47,000, well under budget.
The ACR is the leader in setting standards for
Shaun Ruddy, MD: Chairman, Division of Rheumatology,
Allergy, and Immunology, Medical College of Virginia, Virginia
Commonwealth University, Richmond, and President, American
College of Rheumatology, 1994-1995.
Address reprint requests to American College of Rheumatology, 60 Executive Park South, Suite 150, Atlanta, GA 30329.
the treatment of rheumatic diseases. As we proceed
with this activity, some general observations about
practice guidelines-defined by the Institute of Medicine (7) as “systematically developed statements to
assist practitioner and patient decisions about appropriate health care for specific clinical circumstances”-are appropriate.
1. Guidelines are breaking out all over. The
current (1992-1995) MEDLINE database contains
1,434 postings for the publication type “Practice
Guidelines.” For the last few years, guidelines have
appeared steadily at a rate of more than 400 per year.
There are no signs of slowing down. At an estimated
cost of $100,000 per guideline, this amounts to more
than $40 million per year, roughly 0.004% of our
national costs of health care. The ACR is not alone in
the field: organizations other than the ACR have
produced guidelines relating to rheumatology, including the use of the erythrocyte sedimentation rate,
management of carpal tunnel syndrome, acute low
back pain, and pain in various joints. The Swedish
have weighed in with recommendations about therapy
for rheumatoid arthritis (8), and the British have taken
a crack at the “acute hot joint” (9). The Infectious
Disease Society of America has recommendations for
the antibiotic treatment of infectious arthritis (10,ll).
The exponential growth in the number of guidelines should be arrested by collaborative efforts among
specialties and subspecialties to develop universal
guidelines that specify the best patient care, rather
than pruprietury guidelines that protect practice turf.
The ACR has already entered into such collaborative
arrangements, and will do more.
2. Guidelines come in all sizes and flavors.
Were medicine an exact science, guidelines would be
based exclusively on analyses of the scientific evi-
dence. The ACR guidelines on antibiotic treatment of
fibromyalgia symptoms in suspected Lyme disease
exemplify this approach: they rigorously examine all
parameters and make conclusions about costeffectiveness that are based strictly on evidence. Although such evidence-based guidelines are ideal, reality requires settling for something less. Constraints of
time and cost, and the lack of decisive evidence
precludes purism in developing guidelines. The ACR
Guidelines for O A are hybrids, in which the clinical
evidence is carefully weighed when it is available, and
supplemented with expert opinion when it is not. Such
hybrids are preferable to guidelines which make no
attempt to analyze the evidence, and rely solely on
3. Guidelines are works in progress. Medical
care is constantly changing, as new information and
new diagnostic or treatment modalities appear. When
new therapies for O A become available, the ACR
Guidelines for OA must change to reflect this. As the
number of ACR guidelines increases, significant
amounts of volunteer and staff time will be required to
maintain their currency.
4. The usefulness of guidelines remains uncertain. When internists were queried about the Clinical
Efficacy Assessment Project of the American College
of Physicians, between 11% and 59% said they were
familiar with the actual guidelines, and 7% said they
were familiar with guidelines that didn’t exist (12,13).
Most of the internists (65%) thought the guidelines
would improve quality of care, but most (68%) also
thought the guidelines were likely to be used in physician discipline. When obstetricians were asked about
the content of guidelines with which they professed
awareness, the rate of correct responses was poor.
The same study concluded that the guidelines had little
effect on actual obstetric practice (14). Simple awareness of guidelines has usually not changed physician
behavior; rewards or punishments have been more
successful. The next leap, in which guidelines are
translated into “report cards” for patients to use in
assessing the adequacy and appropriateness of health
care, is essentially unexplored.
Guidelines are being developed to improve the
quality of medical care. Although it remains to be seen
whether or not they will accomplish this goal, they are
intended as a means toward that end. In the long run,
it is the end result--the medical outcome-that
counts. The natural history of most rheumatic diseases
is denominated in years or even decades. In order to
know if guidelines are worth the trouble, we need to
study their effects on outcomes in the rheumatic
1. Hochberg MC, Altman RD, Brandt KD, Clark BM, Dieppe PA,
Griffin MR, Moskowitz RW, Schnitzer TJ: Guidelines for the
medical management of osteoarthritis. Part 1. Osteoarthritis of
the hip. Arthritis Rheum 38:1535-1540, 1995
2. Hochberg MC, Altman RD, Brandt KD, Clark BM, Dieppe PA,
Griffin MR, Moskowitz RW, Schnitzer TJ: Guidelines for the
medical management of osteoarthritis. Part 11. Osteoarthritis of
the knee. Arthritis Rheum 38:1541-1546, 1995
3. Campbell PM, Wilske K: Guidelines for Reviewers of Rheumatic Disease Care. Edited by AL Weaver. Atlanta, American
Rheumatism Association, 1986
4. Lightfoot RW Jr, Luft BJ, Rahn DW, Steere AC, Sigal LH,
Zoschke DC, Gardner P, Britton MC, Kaufman RL: Empiric
parenteral antibiotic treatment of patients with fibromyalgia and
fatigue and a positive serologic result for Lyme disease: a
cost-effectiveness analysis. Ann Intern Med 119503-509, 1993
5 . Kremer JM, Alarc6n GS, Lightfoot RW Jr, Willkens RF, Furst
DE, Williams HJ, Dent PB, Weinblatt ME: Methotrexate for
rheumatoid arthritis: suggested guidelines for monitoring liver
toxicity. Arthritis Rheum 37:316-328, 1994
6. Felson DT, Anderson JJ, Boers M, Bombardier C, Chernoff M,
Fried B , Furst D, Goldsmith C, Kleszak S , Lightfoot R, Paulus
H, Tugwell P, Weinblatt M, Widmark R, Williams HJ, Wolfe F:
The American College of Rheumatology preliminary core set of
disease activity measures for rheumatoid arthritis clinical trials.
Arthritis Rheum 36:72%740, 1993
7. Institute of Medicine: Clinical Practice Guidelines: Directions
for a New Program. Washington, DC, National Academy Press,
8. Recommendations from an expert group: drug therapy of rheumatoid arthritis. Lakartidningen 89: 1923-1926, 1992
9. Guidelines and a proposed audit protocol for the initial management of an acute hot joint: report of a Joint Working Group of
the British Society for Rheumatology and the Research Unit of
the Royal College of Physicians. J R Coll Physicians Lond
26:83-85, 1992
10. Norden C, Nelson JD, Mader JT, Calandra GB: Evaluation of
new anti-infective drugs for the treatment of infectious arthritis
in adults. Infectious Diseases Society of America and the Food
and Drug Administration. Clin Infect Dis I5 (suppl 1):S167S171, 1992
11. Nelson JD, Norden C, Mader JT, Calandra GB: Evaluation of
new anti-infective drugs for the treatment of acute suppurative
arthritis in children. Infectious Diseases Society of America and
the Food and Drug Administration. Clin Infect Dis 15 (suppl
l):S172-S176, 1992
12. Dans PE: Credibility, cookbook medicine, and common sense:
guidelines and the College. Ann Intern Med 120:966-967, 1994
13. Tunis SR, Hayward RS, Wilson MC, Rubin HR, Bass EB,
Johnson W, Stan EP: Internists’ attitudes about clinical practice
guidelines. Ann Intern Med 120:956-963, 1994
14. Lomas J, Anderson GM, Domnick-Pierre K, Vayda E, Enkin
MW, Hannah WJ: Do practice guidelines guide practice? The
effect of a consensus statement on the practice of physicians. N
Engl J Med 321:13061311, 1989
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