Thursday, June 06, 2013

Guideline Apathy

With yesterday's publication of the 2013 ACCF/AHA Guidelines for the management of heart failure, the 101st guideline for cardiologists since 2005 published jointly by the ACC and American Heart Association appeared in the literature (if my count is correct).  Then again, the National Guideline Clearing House set up by our own US Government suggests there are 483 previous guidelines pertaining to cardiovascular diseases, but only 52 published by either the AHA or ACCF for cardiologists.  Does ANYONE know how many guidelines there are for us to review and stay current with?  Which version should we apply to patient care?  When new guidelines are published, how long do we have to implement the new recommendations for care in real life?  Given the pace of medical innovation worldwide, are new guidelines already obsolete once they're published?

With so many publications, constantly updated over and over again, each new set of guidelines joins the maw of guideline publications for physicians that are increasingly ignored.  Worse, the level of evidence for most guidelines are meager at best.  As a result, their importance has been relegated to armament for legal authorities rather than eagerly anticipated recommendations for care.  It has also become clear that payors don't follow these guidelines for payment decisions either; instead they turn to their internal corporate medical coverage policies. 

It would be helpful to have a "What's New" section in the guidelines but, alas, we must repeatedly endure the rambling preamble that rehashes methodology and hope we don't miss the important stuff contained in these tombs when new versions are published.  Despite their effort to be all-encompassing, nuances in complex medical care inherent to sick patients with multiple organ system diseases limit the applicability of these documents in many cases.  So doctors practice their art as they always have: with care and compassion and their best clinical judgment. 

It's too bad, guidelines were once helpful years ago.  Now, clinical doctors are officially numb to them, just like they're numb to ubiquitous telemetry alarms that are overused and constantly ring on our wards. 


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