Clinical Guidelines, the Politics of Value, and the Practice of Medicine: Physicians at the Crossroads

Cooper, Richard A.; Straus, David J.

doi:10.1200/jop.2011.000500

Cited by 4 publications

(5 citation statements)

References 36 publications

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“…Although the summary recommendations can be interpreted as being very rigid, the guideline document puts these recommendations into context with plenty of room for personalization for individual patients. This context is especially important given that guidelines as a whole tend to be simplifications, which makes them easier to remember and implement but can result in the misclassification of individual patients 286,287 . In the 5 years since the publication of the KDIGO guideline, new clinical data has become available, novel therapies have emerged and other lipid management guidelines have been published.…”

Section: [H1] the Kdigo Clinical Practice Guidelinementioning

confidence: 99%

Lipid management in patients with chronic kidney disease

Ferro¹,

Mark²,

Kanbay³

et al. 2018

Nat Rev Nephrol

179

142

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Glomerular filtration rate is inversely associated with cardiovascular disease independent of conventional risk factors. An increased risk of cardiovascular disease is present even at minor levels of renal impairment and the risk is highest in patients with endstage renal disease (ESRD) requiring dialysis. Renal dysfunction changes the level, composition, and quality of blood lipids in favour of a more atherogenic profile. Patients with advanced chronic kidney disease or ESRD have a characteristic lipid pattern of hypertriglyceridemia and low HDL-cholesterol levels but normal LDL-cholesterol levels. In the general population, a clear relationship exists between LDL-cholesterol, coronary heart disease and ischaemic stroke. However, in patients with ESRD, LDL-cholesterol seems to show a negative association [Au: with these outcomes?] at below average LDL-cholesterol levels and a flat or weakly positive association with mortality at higher LDL-cholesterol levels. Overall, the available data suggest that lowering of LDL-cholesterol is beneficial for prevention of major atherosclerotic events in patients with chronic kidney disease and in kidney transplant recipient but is not beneficial in patients requiring dialysis. [Au: I've moved the description of the content of your Review to the end of the introduction as per our journal style. To fully reflect the content of your article, please finish off the abstrace with a couple of sentences relating to novel lipid-lowering therapies and the need for reconsideration of the KDIGO guidelines in the light of new data. We have a limit of 200 words for this section.] [Au: I have highlighted suggestions for glossary terms throughout your manuscript with a [G]. Please provide succinct, one-sentence definitions for these specialist terms.] [H1] Introduction Guidelines regarding the management of lipids in patients with chronic kidney disease (CKD) and especially in those with end-stage renal disease (ESRD) are inconsistent in part owing to important deficiencies in the available data. [Au: Edit OK?] In 2013 KDIGO produced a comprehensive clinical practice guideline for lipid management in CKD 1. [Au: I suggest that we cite your original Table 1 (now Table 3) in the discussion of KDIGO recommendations at the end of the review so that the table is included next to this discussion in the final layout rather than in the introduction to the Review.

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Section: [H1] the Kdigo Clinical Practice Guidelinementioning

confidence: 99%

Lipid management in patients with chronic kidney disease

Ferro¹,

Mark²,

Kanbay³

et al. 2018

Nat Rev Nephrol

179

142

View full text Add to dashboard Cite

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“…Practically, their use by physicians in the course of treatment decisions has proved to be invaluable. While cost is not implicit, philosophically guidelines operate at “value” level, a paradigm that links quality and cost 3 . Not surprisingly in West it is used to determine reimbursement of a procedure.…”

mentioning

confidence: 99%

“…Using the guidelines for quality care delivery depends on the judgment of only those physicians who are trained to cope with complexity and uncertainty and who understand the nuanced characteristics of their patients’ particular circumstances.Guidelines are expressions of the optimal pathway for the average patient, but, of course, most patients are not average 4 . As a matter of fact there is a possibility that the doctrinaire application of guidelines to all patients can be harmful as shown in a recent study which revealed that the inflexible use of the most widely accepted hypertension guidelines would lead to inferior outcomes 3 The measures of effectiveness of guidelines may be quite narrow, and many deal with processes of care or patient satisfaction, neither of which correlate with clinical outcomes.…”

mentioning

confidence: 99%

“…Guidelines are expressions of the optimal pathway for the average patient, but, of course, most patients are not average 4 . As a matter of fact there is a possibility that the doctrinaire application of guidelines to all patients can be harmful as shown in a recent study which revealed that the inflexible use of the most widely accepted hypertension guidelines would lead to inferior outcomes 3 …”

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confidence: 99%

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Western guidelines or practice algorithms?—Yorkshire Pudding or Dal Makhni!

Mishra

2016

Indian Heart Journal

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Physicians to be able deliver contemporary care need to be updated on the recent developments in diagnosis and treatment. However, there is numerous data available practically on each and every aspect of day-today clinical practice. Clinical guidelines may provide a quick solution for everyday problems but many times they themselves are too many, too voluminous and may confuse more than simplify. More-over, they are based on Western derived clinical data, even clinical practice, developed for ethico-legal and reimbursement purposes and therefore may not be applicable to clinical practice in majority of the world. Thus there is a need to develop simple management algorithms which can be used by physicians from developing world who are often constrained by availability, accessibility and affordability.

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“… 3 However, restricting flexibility in the treatment decision may in the end jeopardize patient-centered care. 4 Cooper and Strauss discuss their concern for the potential tyranny of guidelines in a recent paper, stating that “guidelines are expressions of the optimal pathway for the average patient, but, of course, most patients are not average (pp.233).” 5 Finding the correct balance between following guidelines and patient-centered care is relatively uncharted territory and open to scientific inquiry.…”

mentioning

confidence: 99%

Use of Statins by Medicare Beneficiaries Post Myocardial Infarction

Schroeder

Robinson

Chapman

et al. 2015

INQUIRY

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Even though guidelines strongly recommend that patients receive a statin for secondary prevention after an acute myocardial infarction (MI), many elderly patients do not fill a statin prescription within 30 days of discharge. This paper assesses whether patterns of statin use by Medicare beneficiaries post-discharge may be due to a mix of high-quality and low-quality physicians. Our data come from the Centers for Medicare & Medicaid Services (CMS) Chronic Condition Data Warehouse (CCW) and include 100% of Medicare beneficiaries hospitalized for an acute myocardial infarction in 2008 or 2009. Our study sample included physicians treating at least 10 Medicare fee-for-service beneficiaries during their MI institutional stay. Physician-specific statin fill rates (the proportion of each physician’s patients with a statin within 30 days post-discharge) were calculated to assess physician quality. We hypothesized that if the observed statin rates reflected a mix of high-quality and low-quality physicians, then physician-specific statin fill rates should follow a u-shaped or bimodal distribution. In our sample, 62% of patients filled a statin prescription within 30 days of discharge. We found that the distribution of statin fill rates across physicians was normal, with no clear distinctions in physician quality. Physicians, especially cardiologists, with relatively younger and healthier patient populations had higher rates of statin use. Our results suggest that physicians were engaging in patient-centered care, tailoring treatments to patient characteristics.

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Clinical Guidelines, the Politics of Value, and the Practice of Medicine: Physicians at the Crossroads

Abstract: Best practice guidelines are being used to an increasing degree, not only by physicians to improve the level of care, but also by bureaucrats to constrain reimbursement and guide the pathways of care.

Cited by 4 publications

References 36 publications

Lipid management in patients with chronic kidney disease

Lipid management in patients with chronic kidney disease

Western guidelines or practice algorithms?—Yorkshire Pudding or Dal Makhni!

Use of Statins by Medicare Beneficiaries Post Myocardial Infarction

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