Essay On Consensus and Medical Practice Guidelines

The medical guideline movement in the United States began in the mid 1980's when The National Institutes of Health came under intense pressure from policy makers to provide a formal system of assessing new medical developments. This evolved into the NIH Consensus Development Program which was proposed as a means of allowing "appropriate members of the medical professions, the research community, consumers (sic!) and others to join in evaluating new technologies." Ultimately this developed into The Agency for Health Care Policy Research (AHCPR) which was established by Congress in 1989. (P.L. 101-239) The AHCPR is described on their web site, www.ahcpr.gov

The Agency has gradually shifted from the development of guidelines to supporting research in guideline development. Thanks to the emergence of "evidence-based medicine," a major area of policy focuses on "Outcomes and Effectiveness and Technology Assessment." Of special interest is the internet address www.ahcpr.gov/news/press/ngcfrpr.htm where the AHCPR currently invites "health care organizations as well as other public-and private sector entities to submit their clinical practice guidelines for inclusion in the National Guideline Clearinghouse (TM)(NGC), a comprehensive electronic database."

In an excellent editorial overview of the subject (Fletcher,SW, Fletcher,RH. Development of Clinical Guidelines. Lancet 1998;352:1876) the authors point out that in 1997 The American Medical Association listed 2200 guidelines, and that within 6 weeks in the same year two governmentally sponsored groups issued opposing guidelines on screening mammography. Other disparities abound. For example, guidelines for colon cancer screening differ between the National Cancer Institute and the American Cancer Society, and up to 50% of cardiologists in a national study disagreed on indications for invasive studies. In both Britain and the US guideline development is evolving from expert opinion to review of the effectiveness of medical practice, i.e. evidence-or outcomes-based assessment. Up to now neither the UK nor the US have taken into account such issues as quality of life, patient preference for alternative outcomes, and especially the "hazards and hassles" imposed by medical care. Moreover, cost effectiveness has not regularly been considered as part of the equation.

Unfortunately, most consensus views are still achieved by contention, compromise or by selection of an expert panel or organization whose views conform to each other. When these consensus positions described as "Medical Guidelines" edge into "Community Standards of Care" such pronouncements are not uniform or consistent, and carry ambiguous if not dubious legal authority. Far too often they express specialty bias and by implication economic self-interest. Consider the increasing abandonment of established, effective diagnostic and therapeutic procedures for invasive, expensive, and dangerous ones.

Widespread emphasis on economic issues, however, should never serve as an excuse to compromise good medical practice. The economic survival of health care plans is not, as many people believe, in conflict with the practice of sound, yet cost-effective medicine.