Physiatry Practice Management Resources

If you have been using the same practice guidelines for years, it may be time for an update. A new study in JAMA recommends that guidelines be reviewed every three years.

Fail to revise them, and patients may be the ones to suffer.

"Patients won't be getting the full benefit because the latest research is not in the guideline," said Paul Shekelle, MD, PhD, lead researcher of the JAMA study and a health policy analyst for Rand, a nonprofit research and analysis institution.

Dr. Shekelle and other researchers examined 17 clinical practice guidelines published by the federal Agency for Healthcare Research and Quality. The recommendations deal with illnesses such as cancer and depression.

The study, which ran in the Sept. 26 Journal of the American Medical Association, found that more than 75% of the AHRQ guidelines need updating. Seven need a major update, including guidelines for heart failure, cataracts and sickle cell disease.

For example, two new therapies for sickle cell disease are now available -- hydroxyurea and bone marrow transplantation -- the study said.

Six guidelines require a minor update, including ones for lower back problems and management of cancer pain. No conclusion was reached on a guideline for quality determinants of mammography.

Only three guidelines remained valid: prevention of pressure ulcers, treatment of pressure ulcers and cardiac rehabilitation.

The study said half of the guidelines were outdated in less than six years, concluding that guidelines need to be reviewed every three years.

"We just can't put these guidelines out there and not maintain them. They will go bad," Dr. Shekelle said.

AHRQ funded the study because it had concerns the guidelines were out of date, said AHRQ spokeswoman Karen Migdail. Of the 17 guidelines studied, all but the three valid ones were removed from the agency's Web site in May after it received the study's findings, she said.

AHRQ stopped developing guidelines in 1997 and will not update the removed guidelines, Migdail said.

Many physician groups and health organizations offer practice guidelines to doctors. Some contribute the recommendations to the National Guideline Clearinghouse, an online database of evidence-based guidelines sponsored by AHRQ in partnership with the AMA and American Assn. of Health Plans.

Organizations often issue new or revised guidelines to keep up with medical advances.

"You have to review all the articles that have been published to make sure there isn't information that you're not aware of," said Ted Ganiats, MD, a La Jolla, Calif., family physician and former chair of the American Academy of Family Physicians' commission on clinical policies and research.

In September, the American Heart Assn. published in its journal Circulation revised prevention guidelines for heart attack survivors, urging wider use of beta-blockers and ACE inhibitors and more aggressive control of risk factors.

Evidence from recent clinical trials prompted the AHA and the American College of Cardiology to update the guidelines from the original recommendations issued in 1995. The findings include research that said hormone replacement therapy is ineffective in preventing heart attacks in women with cardiovascular disease.

This month, the American Academy of Pediatrics released new guidelines for treating school-age children with attention-deficit/hyperactivity disorder.

Reviewing and updating guidelines helps doctors provide better quality of care, physicians said.

"Medicine is changing constantly. We have a large body of evidence that's published each and every other month, and physicians have a hard time keeping up with all of the information that comes across their desk," said Raymond Gibbons, MD, chair of the ACC-AHA task force on practice guidelines and co-director of the nuclear cardiology lab at the Mayo Clinic in Rochester, Minn.

The American College of Physicians--American Society of Internal Medicine issues its guidelines in the Annals of Internal Medicine and contributes some to the online clearinghouse, said Vincenza Snow, MD, the group's senior medical associate for scientific policy. In May 2000, ACP-ASIM began putting expiration dates on its guidelines.

Guidelines are reviewed annually to determine if they need updating or should be scrapped, said Dr. Snow, who oversees the college's guidelines. The recommendations should be reviewed regularly to incorporate new research and treatments, she said.

"In the past, many guideline developers would put out guidelines, and those would be our little orphans out there, and we would never touch them again," Dr. Snow said.