SIU 2019: Hellenic Urological Association Lecture: Clinical Practice Guidelines - The Unmet Needs

Athens, Greece (UroToday.com) Dr. Dionysios Mitropoulos gave a presentation on the unmet needs of clinical practice guidelines. 

Clinical practice guidelines are systematically developed statements that intend to assist clinicians and patients in making decisions about appropriate health care in specific circumstances.

Guidelines aim to¹:

1. Improve the quality of patient care by encouraging interventions of proven benefit and discouraging the use of ineffective or potentially harmful interventions
2. Reduce unnecessary variation in practice
3. Lessen disparities
4. Empower patients
5. Influence public policy

According to Dr. Mitropoulos, there are still some open questions regarding guidelines. These include the recommendations section of guidelines – do we need to report or interpret the evidence? Should the guidelines be global or national? Are guidelines cost-effective? Are they implemented well-enough? And does the adherence lead to better health-related outcomes?

When attempting to answer the question of whether to report or interpret the evidence, we need to know if we should use evidence-based (EBM) or consensus-based guidelines (CBG). EBM is about using the best available evidence to direct clinical decision-making. It offers guidance on how to use the evidence from varying types of studies, and it aims to optimally help patients make the best decisions consistent with their circumstances and values.

The quality of evidence used in guidelines is extremely important. If the quality of evidence is high, does the evidence speak for itself? And what happens when the quality of evidence is low?

Another important dilemma is what to do when the balance between the benefit or burden is very close – a good example is the adverse effects of chemotherapy that accompany only a small prolongation of life, or the required long time of serial cancer screening for a small absolute benefit in disease-specific mortality. In these cases, guideline panel members are challenged with evaluating the evidence regarding patients’ values and preferences and deciding whether all or almost all fully informed individuals would make the same choice. An important point made by Dr. Mitropoulos is that evidence by itself is never enough, and we always need to translate the evidence into clinically meaningful guidance.

CBG should aim to bridge the gap between knowing and doing. The more the guidelines are focused on the gold standard, the more they become irrelevant in large parts of the world. Guideline makers seem to have no interest in a silver or bronze standard. If continuing to adhere to gold standard concepts, available in only a small part of the privileged world, should the guidelines also have a disclaimer stating that the content is only applicable in that part of the privileged world? The important topic in this discussion is not the evidence but rather the available resources. By focusing on evidence, we increasingly make it difficult for guidelines to be relevant and applicable in countries and areas outside of the privileged sections of the world.

Cost analysis is another important issue, and it was found that 57% of the most commonly used guidelines do not use any cost justification². A shift is needed in this area.

The implementation of guidelines is a fundamental issue that needs to be addressed. A new field, called implementational science, draws on important fields to close the widely recognized gap between evidence-based clinical interventions and their use in routine care. There are many barriers, interventions, and strategies in guideline implementation. These include but are not limited to physician’s knowledge and attitudes, lack of evidence, complexity, access, organizational constraints, lack of resources, social and clinical norms, and many others³.

However, even if there is proper development, dissemination, implementation, and adherence to the guidelines, this does not guarantee an improved quality of care. Dr. Mitropoulos concluded his talk stating that the developers of guidelines should not only focus only on guideline production but also on:

- Clarity
- Including alternatives
- Considering financial issues
- Developing effective implementation strategies
- And providing data on their effect on the quality of healthcare and health-related outcomes

Presented by: Dionysios Mitropoulos, MD, PhD, FEBU, Professor of Urology, Department of Urology, National and Kapodistrian University of Athens, Athens, Greece

Written by: Hanan Goldberg, MD, Urology Department, SUNY Upstate Medical University, Syracuse, New York, USA, Twitter: @GoldbergHanan at the 39th Congress of the Société Internationale d'Urologie, SIU 2019, #SIUWorld #SIU2019, October 17-20, 2019, Athens, Greece