Are the clinical guidelines you use obsolete?
Forty years ago, a physician could single-handedly process enough of the existing medical knowledge to competently manage most situations. Today, with approximately 7 million medical articles in print, that is impossible.
One solution to the problem of “too much” information has been the development of clinical guidelines to help doctors select diagnostic and treatment interventions. Guidelines typically are developed by a national organization to address an important issue, such as urinary incontinence, HIV/AIDS, or smoking cessation. An expert panel is convened to review the available evidence and make recommendations on the state of the art in diagnosis and treatment. Guidelines are a powerful way to systematically approach common clinical issues. When used appropriately, they also improve outcomes and decrease costs.1
More than 1,000 clinical guidelines are available online at the National Guideline Clearinghouse (www.guideline.gov), a site sponsored by the U.S. Agency for Healthcare Research and Quality (AHRQ), the American Medical Association (AMA), and the American Association of Health Plans (AAHP). But even though the Clearinghouse does not retain guidelines unless they have been developed, reviewed, or revised within the past 5 years, a significant number of these may be out of date. When investigators in a recent study explored whether 17 guidelines published by the AHRQ (and still circulating) were current—by asking the chairpersons of the expert panels that developed them to review the latest literature—they discovered that 13 were out of date.2
Many reasons account for this obsolescence, among them the introduction of new diagnostic and treatment options, the publication of additional evidence on the relative benefits and risks of existing alternatives, and changes in how the benefits and side effects of treatments are perceived. Once an expert panel completes a guideline, it often takes about a year to publish a print version. Further, many organizations fail to develop a methodical approach to updating guidelines.
We need to pay close attention to the age of any guidelines we use to ensure that our patients get medical care based on the latest information.
So what guidelines were suggested for keeping guidelines current? In the study just mentioned, a major update was thought to be required when new evidence called into question 1 or more of a guideline’s principal diagnostic or treatment recommendations. A minor update was deemed necessary when the principal diagnostic and treatment recommendations remained valid but new evidence supported changes to other recommendations or greater refinement of existing proposals. Of the 17 guidelines studied, 7 needed a major update and 6 needed a minor update. The researchers also concluded that guidelines should be revised at least every 3 years.
Print guidelines are especially likely to become outdated unless the sponsoring organization establishes a method of notifying practitioners when old documents should be replaced. The American College of Obstetricians and Gynecologists (ACOG) has taken a leadership role in this regard. Each year it provides its members with an updated compendium of the active educational bulletins and committee opinions it has prepared—an excellent way of managing published educational materials.
Organizations with no plans to systematically update their guidelines should include at least 3 important dates: the date the guideline was issued, the date it was last updated, and the date after which the reader should search for an amended or more current guideline. Moreover, every organization needs to determine whether it will systematically update its materials or allow them to “expire.”
In the 21st century, medical knowledge will continue to be characterized by the massive amount of data available and the rapid pace at which new statistics are added, making informed—and timely—guidelines all the more important. As physicians, we need to pay close attention to the age of any guidelines we use to ensure that our patients get medical care based on the very best—and latest—information.
1. Woolf SH, Grol R, Hutchinson A, Eccles MP, Grimshaw J. Clinical guidelines: potential benefits, limitations and harms of clinical guidelines. BMJ. 1999;318:527-530.
2. Shekelle PG, Ortiz E, Rhodes S, et al. Validity of the Agency for Healthcare Research and Quality Clinical Practice Guidelines: how quickly do guidelines become outdated? JAMA. 2001;286:1461-1467.