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

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. Copyright Â

The whole occidental savoir-faire is based on materialism and money and health-care is no exception. Indeed for some medical reimbursement is the most important part of medical industry—anything that “pays” is “good.” Thus their focus on “Guidelines,” developed for fair reimbursement is not surprising. However, Oriental philosophy is somewhat contradistinctive; it is concerned with “What is the right and what is the right way of doing things” rather than “what pays.” Further, Western reimbursement model, or even any reimbursement model is not applicable in context of our countries like India where 90% patients pay from pocket. Thus there is no need for every country to participate in Western motivated “Guideline Dialogue.” Rather this unwarranted focus on western guidelines may be futile for the vast majority as this model is based on the practice environment prevalent in a given area which may be markedly different from other areas. For instance talking of cardiac assist devices in countries where they are not even available or percutaneous valve replacement therapies where vast majority of individuals cannot afford it is rather meaningless. The “need of the hour” is regional practice based Management Protocols i.e. the right way to do things. On the contrary, at present (perhaps because of our colonial mind-set, or because we do not delve deep enough in anything) we are focused on re-working guidelines despite the fact that there is not enough data to develop region specific guidelines.

Physicians in an attempt to give their patients the best possible care need to be updated on the recent developments in diagnosis and treatment. However, they are inundated with numerous data for which neither they have time (to go through) nor they understand it well. In this context clinical guidelines provide a quick solution for day-to-day problems and thus serve as important adjuncts to clinical decision making. 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. Not surprisingly in West it is used to determine reimbursement of a procedure. From physicians perspective they are modus operandi for “defensive medicine”—extra tests and procedures done principally to forestall law-suits or defend them if brought—which increases costs and reduces quality. In other words they have an important ethico-legal context (in the garb of evidence based medicine) rather than “true value” for physician or patient. That apart, there are three broad practical limitations of guidelines in context of day-to-day practice:

The way they are framed they confuse more than guide an average physicians. An average physician inevitably gets confused by the jargon of IA, IIB, etc. 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. 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.

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. Patients’ values defined as “the unique preferences, concerns and expectations each patient brings to a clinical encounter are one of the most important considerations. The common substrate to develop guideline is evidence based medicine and evidence-based medicine has been defined as “the integration of best research evidence with clinical expertise and patients’ values,” not necessarily patient outcomes.

Thus although many of the most clinically useful guidelines deal with important issues, it is through their exercise of judgment in myriad small decisions that physicians display their competence. On the contrary inflexible use of guidelines can adversely affect such decisions. In general they are just guides, are provisional and should not be applied for regulation of practice. Thus what we need are not guidelines but practice standards which are:

Easily understood by physicians.

Cover the entire spectrum of clinical and economic practice.

Focus on clinical outcomes.

Reliable clinical practice guidelines have potential to help by authoritatively stating standards of good care in advance. They promise a rare trifecta—better medical quality, more cost restraint through limits on liability's influence over medicine, and a potential avenue for political compromise on malpractice reform.