Clinical practice guidelines
1
Australasian Psychiatry • Vol 11, No 3 • September 2003 345 Clinical practice guidelines DEAR SIR, The paper by Tobin et al. in the March 2003 issue of Australasian Psychiatry says that the College decision to develop clinical practice guide-lines (CPGs) is not about enforcing stan- dardized practice. 1 However, the authors go on to say that CPGs should be used to assess variance in practice. Use of the CPGs in this way would be a proxy for enforcing stan- dardized practice. Variance analysis (and the ‘correction’ of variance- reducing practice diversity) is usually associated with the monitoring of critical care pathways. These critical care pathways are quite detailed and are specific to services and clinical situations where a homogenous patient population or a well-defined clinical problem can be approached with a uniform protocol (such as preadmission, admission and dis- charge procedures for hip replace- ment surgery). Situations like this are fairly unusual in psychiatry (although a few might be identified). Critical care pathways are frequently used by institutions to enforce practice behaviour, and often to reign in costs. The design of critical care pathways is frequently informed by relevant CPGs, but variance analysis (monitoring practice deviations from the pathway) is usually reserved for evaluating the utility of the pathway, rather than the much broader appli- cation suggested by Tobin et al. The use of CPGs as variance tools is a misuse of CPGs and will lead to them coming into disrepute. Uncritical acceptance of this use will encourage groups within and outside the profes- sion to interpret CPGs literally in order to claim support for a treatment or to limit treatment alternatives. The CPGs are a statement of a con- sensus view (based on what evidence and opinion might be available) of a collection of professionals on a com- mittee at a certain time in history, and are probably out of date as soon as they are published. The substantial use of level III, IV and V evidence in the guidelines means that the inter- pretation of this evidence by com- mittee members is critical yet not infallible, thus limiting the authori- tativeness of the CPGs. The CPGs have their limitations (also noted by the College CPG Programme team 2 ), including being rigid, not taking into account comorbidities, and non-medical preferences. 3 Alterna- tives exist that try to correct some of the weaknesses of CPGs. For example, clinical glidepaths are practice guide- lines that are less rigid, appreciate the limitations of evidence-based medi- cine (EBM), emphasize individual patient outcomes, acknowledge the clinical context, and respect patient choice in medical decisions. 3 The more specific and dogmatic the CPGs are, the more they are likely to date and the less likely that they will be adopted by clinicians who work with a diversity of patients suffering from complex problems. Conversely, the more that CPGs outline an approach to a clinical problem or condition, with rational explanations for com- peting treatments, the more they are likely to be accepted. I think that CPGs are valuable but should be used as an informative, educative and training process. To me they are a departure point for further debate about advancing clinical care in a particular area. Perhaps when the next series are published, these thoughts might be considered. REFERENCES 1. Tobin M, Wilson A, Codyre D, Rosen A, Barton D. Clinical practice guidelines: a tool to measure variance. Australasian Psychiatry 2003; 11 : 26–28. 2. Boyce P, Ellis P, Penrose-Wall J. Australian and New Zealand Clinical Practice Guidelines for Specialist Adult Mental Health Care: an introduction. Australa- sian Psychiatry 2003; 11 : 21–25. 3. Flaherty JH, Morley JE, Murphy DJ, Wasserman MR. The development of outpatient clinical glidepaths. Journal of the American Geriatric Society 2002; 50 : 1886–1901. Philip Morris Ashmore, Queensland
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Transcript of Clinical practice guidelines
Australasian Psychiatry
• Vol 11, N
o 3 •
September 2003
345
Clinical practice guidelines
DEAR SIR,
The paper by Tobin
et al
. in the March2003 issue of
Australasian Psychiatry
says that the College decision todevelop clinical practice guide-lines(CPGs) is not about enforcing stan-dardized practice.
1
However, theauthors go on to say that CPGsshould be used to assess variance inpractice. Use of the CPGs in this waywould be a proxy for enforcing stan-dardized practice. Variance analysis(and the ‘correction’ of variance-reducing practice diversity) is usuallyassociated with the monitoring ofcritical care pathways. These criticalcare pathways are quite detailed andare specific to services and clinicalsituations where a homogenouspatient population or a well-definedclinical problem can be approachedwith a uniform protocol (such aspreadmission, admission and dis-charge procedures for hip replace-ment surgery). Situations like thisare fairly unusual in psychiatry(although a few might be identified).Critical care pathways are frequentlyused by institutions to enforcepractice behaviour, and often to reignin costs. The design of critical carepathways is frequently informed byrelevant CPGs, but variance analysis(monitoring practice deviations fromthe pathway) is usually reserved forevaluating the utility of the pathway,rather than the much broader appli-cation suggested by Tobin
et al
. Theuse of CPGs as variance tools is amisuse of CPGs and will lead to themcoming into disrepute. Uncriticalacceptance of this use will encouragegroups within and outside the profes-sion to interpret CPGs literally in
order to claim support for a treatmentor to limit treatment alternatives.
The CPGs are a statement of a con-sensus view (based on what evidenceand opinion might be available) of acollection of professionals on a com-mittee at a certain time in history,and are probably out of date as soonas they are published. The substantialuse of level III, IV and V evidence inthe guidelines means that the inter-pretation of this evidence by com-mittee members is critical yet notinfallible, thus limiting the authori-tativeness of the CPGs. The CPGshave their limitations (also noted bythe College CPG Programme team
2
),including being rigid, not takinginto account comorbidities, andnon-medical preferences.
3
Alterna-tives exist that try to correct some ofthe weaknesses of CPGs. For example,clinical glidepaths are practice guide-lines that are less rigid, appreciate thelimitations of evidence-based medi-cine (EBM), emphasize individualpatient outcomes, acknowledge theclinical context, and respect patientchoice in medical decisions.
3
Themore specific and dogmatic the CPGsare, the more they are likely to dateand the less likely that they will beadopted by clinicians who work witha diversity of patients suffering fromcomplex problems. Conversely, themore that CPGs outline an approachto a clinical problem or condition,with rational explanations for com-peting treatments, the more they arelikely to be accepted. I think thatCPGs are valuable but should beused as an informative, educativeand training process. To me they area departure point for further debateabout advancing clinical care in aparticular area. Perhaps when thenext series are published, thesethoughts might be considered.
REFERENCES
1
.
Tobin M, Wilson A, Codyre D, Rosen A, Barton D.Clinical practice guidelines: a tool to measurevariance.
Australasian Psychiatry
2003;
11
: 26–28.
2
.
Boyce P, Ellis P, Penrose-Wall J. Australian and NewZealand Clinical Practice Guidelines for SpecialistAdult Mental Health Care: an introduction.
Australa-sian Psychiatry
2003;
11
: 21–25.
3
.
Flaherty JH, Morley JE, Murphy DJ, Wasserman MR.The development of outpatient clinical glidepaths.
Journal of the American Geriatric Society
2002;
50
:1886–1901.
Philip MorrisAshmore, Queensland
