Medical guidelines are now recognised as central to efforts aimed at reducing the risk of human error and protecting patient safety. Guidelines are particularly invaluable in minimising the risks associated with the ‘increasing complexity of healthcare’, and with the ‘information overload‘ that is associated with modern medicine. Robbie Foy and colleagues made this point writing under the topic ‘Guidelines and Pathways‘ in the book Clinical Risk Management. There, they asserted that guidelines help by their ability to distinguish between ‘actions which are based upon sound evidence‘, from those which ‘depend more upon clinical judgement and patient preference‘.
There are however many other ways by which guidelines improve the quality of care of patients. For example, Wendy Lim and colleagues, in their paper titled Evidence-based guidelines – an introduction, said guidelines prevent errors by ‘supporting interventions of proven benefit‘, and by ‘discouraging interventions that are ineffective or potentially harmful‘. They also highlighted the ability of guidelines to improve ‘the consistency of care’ and ‘the quality of clinical decisions‘. On the other hand, Patrick O’Connor, writing in a paper titled Adding value to evidence-based clinical guidelines, pointed to the ability of guidelines to ‘articulate clear goals of care’ and to ‘reduce undesirable variation in care’.
Despite their proven value in enhancing the safety of patient care, the medical profession as a whole has been reluctant to embrace guidelines in practice. In their paper titled Why don’t physicians follow clinical practice guidelines? A framework for improvement, Michael Cabana and colleagues regretted that despite their proven record of improving patient outcomes, guidelines have had limited effect on ‘the knowledge, attitudes, and behaviour of doctors’. The authors identified several factors responsible for this resistance to the adoption of guidelines, amongst which were:
- Lack of awareness of the guidelines
- The inconvenience of using guidelines
- Lack resources or facilities to implement the guidelines
- The inertia of previous practice
- Different interpretations of the evidence
O’Connor also reviewed other barriers to the adoption and implementation of guidelines which include:
- Inaccessibility at the point of use
- Difficulty implementing them when they contain too many recommendations
- Inappropriateness of the recommendations in particular clinical situations
- Failure to rank the recommendations ‘in terms of their clinical value‘
Whilst guidelines are predominantly beneficial, Lim and colleagues pointed out that they may also ‘be misleading and cause harm‘. They referred to the following as the likely situations when guidelines may be risky:
- When their recommendations are ‘based on an incomplete or flawed dataset‘
- When ‘they are biased‘
- When ‘the development process is incorrectly carried out’
- When ‘the evidence is misinterpreted‘
- When they do not address the needs of patients
David Scalzitti, in his paper titled Evidence-based guidelines: application to clinical practice, also explored other potential problems of guidelines, such as ‘when multiple practice guidelines are published on the same topic’. Whilst he stressed the necessity for guideline recommendations to be clear and uncontroversial, Scalzitti nevertheless argued that it is the doctor’s responsibility to determine the validity of the guidelines, and to understand that ‘the use of evidence in practice is to help reduce uncertainty in decision making, not to eliminate it’.
In the next post, we will look at how to develop effective clinical guidelines.