Saturday, December 8, 2012

What To Do about Worthless Guidelines

While I have been getting behind in my posting, our friends at Health Care Renewal have been on a tear, including this useful piece:

The post summarizes (and also links to) a recent study showing that the majority of clinical practice guidelines fall woefully short of the standards recently recommended by an Institute of Medicine report. I should add here that what the IOM did was not exactly rocket science; they pretty much summarized earlier thoughtful recommendations. So no one could claim that the IOM report came from out of the blue with a bunch of wild and crazy criteria.

What HCR is especially concerned about, suitable for our own purposes in this blog as well, is the frequency of conflicts of interest among guideline writers and chairs of panels, and the general failure of the guideline-sponsoring societies to police or even to disclose such conflicts.

As usual the HCR post makes a number of good points, but I would add a comment on what needs to be done about all this. HCR bemoans the fact that right now, no one has any interest in cleaning up the mess; everyone involved is looking for a way to use guidelines to make a buck. As my friend Dr. Jerry Hoffman of Primary Care Medical Abstracts likes to say, our current fetish for pay-for-performance makes the job of the drug companies and their ilk easy. They used to have to find a way to bribe 800,000 docs to write prescriptions for their pills. Now all they have to do is find a way to bribe about 1000 docs--the ones charged with writing the practice guidelines. Then the P4P folks will tell the rest of the 800,000 that they won't get paid unless they follow the guidelines, and the industry can laugh all the way to the bank.

So what to do if no one has an interest in cleaning up the mess? We have to turn back the clock a bit and recall the history of the Federal agency now called the Agency for Healthcare Research and Quality (AHRQ) which in olden days was the Agency for Health Care Policy and Research (AHCPR). In its AHCPR days, the agency gained a reputation for writing the best clinical practice guidelines around. They usually spent $10M per guideline and the result was highly respected by experts.

One result, however, was not highly respected by one group. The lower back pain guideline that said that surgery was hardly ever warranted as treatment upset a few well-heeled orthopedists, and these guys just happened to have some good friends in Congress. Thanks to that cabal, the next thing you knew, there was an action in Congress to eliminate all funding for AHCPR. AHCPR just barely squeaked by and survived with a major budget cut. But as part of that whole deal, they agreed to stop writing practice guidelines.

AHRQ is now the host of, a central respository where you can find just about any clinical practice guideline written by any group for any disease. Also, if you look at the inclusion criteria at, you'll see that AHRQ exercises virtually no editorial control whatever over the content of the guidelines. So long as some document is the guideline equivalent of a warm body that has a pulse, it goes on the site. And that makes good political sense if you don't want some other influential group of rich docs, who think you're robbing them of their cash cow, lobbying Congress to revoke your funding.

What has to happen, given the widespread promulgation of guidelines that fall abysmally short of any decent standard of quality? Somebody in government has to run interference for AHRQ and have the spinal fortitude to assign them the task of applying all the IOM criteria to each guideline. Now, so far as I care, can stay as it is and collect all guidelines in one handy location; but there then needs to be an inner circle of the real guidelines that actually meet a reasonable subset of IOM quality criteria. The guidelines with the seal of approval have to be carefully labeled and distinguished from the rest. Then maybe the other players in the game, especially the medical specialty societies which are currently among the worst offenders, will finally have an incentive to produce quality products instead of the current drek.

Full disclosure department: I am a member of IOM and spent the year 1993-94 as a visiting scholar at AHCPR.


sbfren said...

So, on the off chance that noone in government does have that sipnal fortitude, or that the interference running takes quite a long time... what can be done in the interim?

Howard Brody said...

Sbfren raises a great question. If we cannot get others to help us sift through the guidelines and separate wheat from chaff, physicians and their organizations must do this ourselves, and push back when insurers try to make us follow bad guidelines. As a primary care doc I wish my own specialty society would be more active in pushing back against the other societies that promulgate conflicted guidelines; but that probably goes against the old boy's club sense of medical organizational politics. Thanks, Howard

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