Medical "best practice" often no more than opinion

NEW YORK Mon Jan 10, 2011 7:31pm EST

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NEW YORK (Reuters Health) - Even when following medical guidelines to the letter, doctors often use treatments that have little or no scientific support, U.S. researchers said Monday.

They found only one in seven treatment recommendations from the Infectious Diseases Society of America (IDSA) -- a society representing healthcare providers and researchers across the country -- were based on high-quality data from clinical trials.

By contrast, more than half the recommendations relied solely on expert opinion or anecdotal evidence.

"Despite tremendous research efforts, there is still a lot of uncertainty as to what is the best patient care," said Dr. Ole Vielemeyer, an expert in infectious diseases at Drexel University College of Medicine in Philadelphia and one of the study's authors.

"A cookie-cutter approach, where you just have a set of guidelines that you apply no matter what, can be dangerous."

For example, he said, 2003 guidelines advising that patients with pneumonia get antibiotics within hours of seeing the doctor ended up producing an increase in mistaken pneumonia diagnoses and treatment, with no apparent benefits. Indeed, prescribing antibiotics unnecessarily exposes people to the drugs' side effects and could help breed resistant bacteria.

The new analysis, published Monday in the Archives of Internal Medicine, is based on more than 4,200 recommendations made by IDSA between 1994 and 2010.

"These data reinforce that absolute certainty in science or medicine is an illusion," an editorial in the journal notes. "Rather, evaluating evidence is about assessing probability."

Vielemeyer said the findings are likely to apply to other areas of medicine as well, and mentioned an earlier study that found similar results in cardiology.

Doctors across the world look to guidelines when deciding how to treat patients, and insurance companies may use them in coverage decisions.

Because they are drafted by leading experts in the field, they are generally understood to reflect the best medical knowledge available. "People commonly associate guidelines with practicing evidence-based medicine," said Vielemeyer.

But often the relevant clinical studies simply haven't been done. In the absence of evidence, the recommendations end up depending largely on who's on the guideline-drafting panel and any assumptions or opinions they may bring to the process.

In 2008, for instance, then-attorney general of Connecticut Richard Blumenthal sued IDSA for stacking a panel with experts who didn't believe in the controversial "chronic" version of Lyme disease, a tick-borne illness.

While the guidelines were upheld by an independent review panel last April, Blumenthal still expressed concern over "improper voting procedures."

"We are operating on a lot of bias," acknowledged Dr. Larry Baddour, who chairs the division of infectious diseases at Mayo Clinic College of Medicine in Rochester, Minnesota, and has been on several IDSA panels. He recently published findings similar to those of the current study in the IDSA's journal Clinical Infectious Diseases.

"We struggle with this, even as experts," he said. "We recognize we have bias, but it's impossible to eliminate when there is a dearth of data."

Diana Olson, spokesperson for IDSA, pointed out that all recommendations list the degree of evidence on which they are based.

"Clinicians understand when there is really rock-hard evidence behind our recommendations and when there isn't," she told Reuters Health, adding that some guidance is better than none at all.

"The public can have absolute confidence in these guidelines," she added. "They remain the best that science and medicine have to offer."

Vielemeyer agreed guidelines offer valuable help to busy doctors.

"As long as you understand that they are just guidelines, I don't think they are detrimental to patients," he said. "But if they are considered as dogma, that is when they can become dangerous to patients."

SOURCE: bit.ly/fPU7xp and bit.ly/ht8Ost Archives of Internal Medicine, January 10, 2011.

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Comments (3)
Joanne60 wrote:
“As long as you understand that they are just guidelines, I don’t think they are detrimental to patients,” he said. “But if they are considered as dogma, that is when they can become dangerous to patients.”

And there you have it – sadly the IDSA much contested Lyme Disease Guidelines were based on poor evidence level according to presentations at their review hearing but the final report chose to ignore all the evidence and make it’s decision on just 4 randomised placebo controlled trials all of which were severely criticised for being under powered and for too short a treatment duration.

Cherry picking research to suit ones opinions does nothing to help patients. Sadly in the case of Lyme Disease these guidelines are responsible for hurting patients leaving them without treatments and allowing Insurance in USA to refuse cover for treatment.

Jan 11, 2011 6:21am EST  --  Report as abuse
Lyme-Aware wrote:
Unfortunately, when it comes to Lyme Disease the guidelines are insufficient. I was refused any additional treatment shortly after the “rubber stamp” treatment failed; within six weeks upon finding the tick and having all the early symptoms, incl bulls-eye (which most don’t) doctors refused to budge. Within six weeks I was completely debilitated.
There is plenty of clinical evidence that shows Bb can persist even after the prescribed treatment as per the guidelines suggest. Hindawi published, Proof the Chronic Lyme Disease Exists, http://www.hindawi.com/journals/ipid/2010/876450.html so why aren’t current Lyme literate medical doctors given the flexibility to treat according to the individual’s needs?
These doctors that are willing to do whatever it takes to help you become well should definitely be given the ability to treat according to the individual’s needs and not undergoing the “witch hunts” that they has been going on. These findings add to the arguments of chronic Lyme Disease sufferers that the current treatment guidelines should be changed.

Jan 11, 2011 2:02pm EST  --  Report as abuse
T-Bone wrote:
The IDSA “Guidelines” nearly killed me. Because the several (read: many) Infectious Disease “specialists” I saw adhered to those guidelines, I was not given the medication that would have prevented Lyme Disease from ravaging my brain and central nervous system, my bones and joints, and finally my heart. After two heart attacks, I STILL cannot receive the intravenous treatments I need, because my doctor insists that the insurance company will use the “Guidelines” to deny paying for that treatment, even though the oral medications I am stuck taking for years are MORE EXPENSIVE in the long run than the intravenous medicine would be, since it very well could cure the horrible suffering caused by this insidious disease in a matter of months. This Disease is causing untold suffering and death all across the nation, yet is denied by the medical establishment, who are so beholden to the insurance companies that the hypocratic oath is now a joke.

Jan 12, 2011 5:48pm EST  --  Report as abuse
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