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Practice Guidelines The Good, The Not-So-Good The Ugly 1

Practice Guidelines

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Practice Guidelines. The Good, The Not-So-Good The Ugly. 1. Where do practice guidelines come from?. Trust us, we’re the experts : Opinion-based/ consensus guidelines Whose opinion? Do they have a conflict of interest? What is their perspective? - PowerPoint PPT Presentation

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Page 1: Practice Guidelines

Practice Guidelines

The Good, The Not-So-Good The Ugly

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Page 2: Practice Guidelines

Where do practice guidelines come from?

Trust us, we’re the experts: Opinion-based/ consensus guidelines• Whose opinion? Do they have a conflict of interest? What is

their perspective? Trust us, we have the evidence: “Evidence-

based”• How was the evidence used? Patient-oriented? Values?

Evidence-linked:• Here is how we found the evidence, used the evidence

• Strength of recommendation noted

Page 3: Practice Guidelines

Guidelines: Ultimately a social exercise

Evidence: It is what it is The human touch:

• Social judgment layered on top of the evidence

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Page 4: Practice Guidelines

Breast Cancer Screening and the USPSTF

The Evidence

Page 5: Practice Guidelines

How They Arrived at these Conclusions

Meta-analysis of 8 randomized controlled trials (RCTs)• Invited a total of 348,219 women at age 40 yrs for

yearly screening

• 0-3 studies, individually, showed a decrease in breast cancer mortality

• Meta-analysis: Combining results from all trials and analyzing the results

• Results:

Page 6: Practice Guidelines

Figure. Nelson HD. Screening for breast cancer: An update for the U.S. Preventive Services Task Force. Ann Intern Med 2009; 151:727-737.

Page 7: Practice Guidelines

Benefits10,000 women ages 40-49 yrs screened yearly

USPSTF Recommendation Statement. Ann Intern Med 2009;151(10):716-726

Page 8: Practice Guidelines

USPSTF Recommendation Grades, 2009

Page 9: Practice Guidelines

USPSTF Recommendation Statement: Breast Cancer Screening

Page 10: Practice Guidelines

Why Does The BenefitSeem To Be So Small?

Page 11: Practice Guidelines

Breast cancer mortality vs all causes of mortality, all ages

Black WC, et al. All-Cause Mortality in Randomized Trials of Cancer Screening. Journal of the National Cancer Institute, Vol. 94, No. 3, 167-173, February 6, 2002

Page 12: Practice Guidelines

Causes of death in women, by age

Bunker JP, Houghton J, Baum M. Putting the risk of breast cancer in perspective. BMJ 1998;317:1307-9.

Page 13: Practice Guidelines

But What About “1-in-8”?

Ave lifespan = 79 years

Bunker JP, et al. Putting the risk of breast cancer in perspective. BMJ 1998;317:1307-9.

Page 14: Practice Guidelines

Risks10,000 women ages 40-49 yrs screened yearly

USPSTF Recommendation Statement. Ann Intern Med 2009;151(10):716-726

Page 15: Practice Guidelines

Pseudodisease (overdiagnosis)

A condition that looks just like the disease, but never would have bothered the patient• Disease that would never cause symptoms

• Asymptomatic disease in people who will die from another cause before disease presents

An estimated 10%-30% of breast cancers found and treated would have never affected the patients• The question: which ones?

Cochrane Database Syst. Rev. 2009;CD001877 doi:10.1002/14651858.CD001877.pub3

Page 16: Practice Guidelines

Overdiagnosis bias

Gigerenzer G, et al. Helping doctors and patients make sense of health statistics. Psychological Science in the Public Interest 2008;8(2):53-96.

Page 17: Practice Guidelines

Evaluating Screening Tests

Fryback DG, Thornbury JR. The efficacy of diagnostic imaging. Med Decis Making 1991; 11:88-94

Page 18: Practice Guidelines

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Can We Trust Guidelines from Specialty Societies?

Or

Never ask a barber if you need a haircut

Page 19: Practice Guidelines

“. . . The guild of health care professionals – including their specialty societies – has a primary responsibility to promote its members’ interests. . .

Quanstrum KH, Hayward RA. Lessons from the mammography wars. N Engl J Med 2010; 363:1076-1079

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Page 20: Practice Guidelines

. . . It is a fool’s dream to expect the guild of any service industry to harness its self-interest and to act according to beneficence alone – to compete on true value when the opportunity to inflate perceived value is readily available.”

Quanstrum KH, Hayward RA. Lessons from the mammography wars. N Engl J Med 2010; 363:1076-1079

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Page 21: Practice Guidelines

Screening for breast cancer: yearly at age 40

American College of Radiology Society of Breast Imaging American Society of Breast Disease American Cancer Society ACOG

Page 22: Practice Guidelines

“Evidence-based” and the evolution of evidence: subclinical hypothyroidism

Step 1 Search of 10 databases Studies summarized 12 experts rated the evidence Recommendations:

• “Recommend against routine screening for subclinical hypothyroidism”

• “Recommend against routine treatment of 4.5 – 10.0 mIU/L”

Surks MI, et al. Subclinical thyroid disease. Scientific Review and Guidelines for diagnosis and management. JAMA 2004;291:228-238.

Page 23: Practice Guidelines

“Evidence-based” and the evolution of evidence: subclinical hypothyroidism

Step 2: Consensus meeting among members of the American Association of

Clinical Endocrinologists, The American Thyroid Association, and The

Endocrine Society.

New recommendation statement

Recommendations sent to leadership of the organizations

Page 24: Practice Guidelines

The evolution of evidence: subclinical hypothyroidism

The result: New recommendations from the three societies:

• Most patients with TSH levels 4.5 – 10 mIU/L should be treated• Shouldperform routine screening for subclinical hypothyroidism

Why?• “Although good evidence is unavailable [to support our

recommendation], there is a sizable amount of fair evidence and an abundance of opinion by experts . . . The [scientific panel recommendations] are contrary to the practice of many. . . experts”

Gharib H, et al. Consensus statement: Subclinical thyroid dysfunction: A joint statement on management from the American Association of Clinical Endocrinologists, The American Thyroid Association, and The Endocrine Society. J Clin Endocrinol Metab 2005;90:581-5.

Page 25: Practice Guidelines

Bilirubin in term infants (Sept 2009)

USPSTF: Summary of Recommendation“The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend screening infants for hyperbilirubinemia to prevent chronic bilirubin encephalopathy”

American Academy of Pediatrics Restatement and Clarification“. . .We recommend universal predischarge bilirubin screening,which helps to assess the risk of subsequent severehyperbilirubinemia. We also recommend a more structured approachto management and follow-up according to the predischarge TSB/TcB,gestational age, and other risk factors for hyperbilirubinemia.These recommendations represent a consensus of expert opinionbased on the available evidence, and they are supported by severalindependent reviewers. Nevertheless, their efficacy in preventingkernicterus and their cost-effectiveness are unknown. “

Page 26: Practice Guidelines

Evidence Linked Guidelines

Brief Summary Statement for each recommendation

Detailed Discussion of the evidence Long Reference section pointing to original

research Methods section showing how evidence was

obtained and evaluated

Page 27: Practice Guidelines

Evidence Linked Guidelines

Brief s

tatementDetailed overview of the evidence

Evidence table

Page 28: Practice Guidelines

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National Guideline Clearinghouse

www.ngc.gov Vetted guidelines from various groups Standard organization so that information can be

compared across various guidelines