In order to stay abreast of the evolving clinical practice standards that are relevant to your day-to-day patient care, you need to know where to find and how to use guidelines. Not only do clinical practice guidelines and standards help you maintain quality of care, but they also help you understand how others—from payers to credentialing committees to medical malpractice litigators—make decisions related to your work.
In his lecture “The Development, Use, and Limitations of Standards, Guidelines, and Best Practices,” now available for CME credit from AudioDigest, Dr. Karl Poterack, MD, provides useful insights into what physicians need to know about clinical practice standards and guidelines.
What are clinical practice standards and guidelines?
The use of guideline-associated terminology can be confusing even for those who are knowledgeable about the subject. What’s important to know is that a variety of formal medical documents can be used to guide clinical practice, including advisories, statements, resources, policies, best practices, guidelines and standards. For example, policies are usually required, but best practices are not, though you could be blamed for not following them if something goes wrong.
The different types of documents are not necessarily all given the same weight by physicians, payers or legal decision-makers. For instance, clinical practice standards may be used to guide reimbursement if payers refuse to cover diagnostics and procedures that are not considered standard. They may also be viewed as benchmarks of quality when physician privileges are being assessed. Failing to achieve or follow standards could be problematic for a physician if an adverse outcome leads to legal action.
Guidelines can protect you if you follow them, and you might face problems if you don’t. Documenting your reasoning when you make decisions that don’t follow guidelines could help protect you from problems later.
How are clinical practice guidelines developed?
There are also guidelines for how to put together guidelines. In guideline development, a committee or task force conducts a review of research-based evidence that’s carried out by looking at the strength of the evidence. They then work together to reach an expert consensus. The choices and their potential benefits and harms are assessed based on standardized criteria as well as real-world experience.
Development of these documents requires transparency regarding who is involved as well as a statement regarding their conflicts of interest.
How can you find and evaluate clinical practice guidelines?
If you haven’t already noticed, there’s an abundance of guidelines in the medical field. You may be able to find resources on your hospital website, through your specialty association or on your state medical board website.
The tricky part is that you might find one set of guidelines that is used by your specialty and another set that is used by your subspecialty. They might not be exactly the same, and they might even contradict each other. For example, one specialty might publish guidelines recommending minimally invasive stenting, while another society recommends surgery for the exact same type of lesion. Simply finding guidelines isn’t always enough—decision-making is almost always part of the process, too.
Sometimes third-party appraisals of guidelines are also available. These authoritative evaluations rate the guidelines by assessing how useful they are and the process that was used for their development. Many guidelines are not evaluated by a third party, while some guidelines might be overseen by different third-party bodies, some of which are mentioned in Dr. Poterack’s lecture. The bottom line is that you can read guidelines, but you might end up only accepting and adhering to those that seem to be high-quality.
How can you use clinical practice standards?
Clinical practice standards can be useful for helping physicians reduce the risk of adverse events and improve the quality of patient care. When each doctor does things differently, residents and support staff may see inconsistencies in care, which can make teamwork difficult due to a lack of predictability. Standardization can also help minimize variation in practices between different clinicians or in different regions or hospitals.
While standardization can be helpful, though, there are limitations to clinical practice guidelines. For example, every patient is different. Some patients don’t fit the guidelines, and sometimes guidelines don’t account for factors like comorbidities. This means that guidelines have value, but they shouldn’t be the be-all and end-all of patient care decision-making.
It takes experience in patient care to be able to understand the nuances that are involved with how to use guidelines. You might refer to guidelines when discussing a difficult case with a multidisciplinary group or when a patient is coming to you for a second opinion. Advisories can be helpful warnings about newly discovered medication warnings that you might want to consider in a subset of your patients. Certainly, you can refer to guidelines if you’re meeting resistance when advocating for your patient. Ultimately, the abundance of guidelines can be overwhelming, so you will have to decide which ones are valuable for you and which ones you can’t ignore.