By Toni Lapp
SpectrumConnection.org
Watch a clip from this panel.
Covering the Release of a New Guideline: Questions to Ask
Fontanarosa suggested reporters ask who, why, what and how:
♦ Who? What agency/group/organization is the source of the guidelines? Who are the study authors?
♦ What is changing from current advice?
♦ Why now? What is the context on the issue?
♦ How? The process used for development should be clearly explained in the guideline or readily available. How was evidence considered for inclusion or exclusion? What is quality of underlying evidence? What is strength of recommendation for guideline, including recognition of uncertainties?
Public perception
Moderator and AP reporter Marilynn Marchione suggested that this Onion headline summed up the public frustration: "Eggs Good For You This Week."
When it comes to clinical practice guidelines, Americans have, no pun intended, developed a healthy skepticism.
"It's as complicated as you think it is," panelist Len Lichtenfield, M.D., deputy chief medical officer of the American Cancer Society told the roomful of journalists attending the panel discussion, "Guidelines for Writing about Preventive Health Guidelines" at Health Journalism 2010 in Chicago.
"You have a difficult job," Lichtenfield said. "You're trying to take something that's complicated, that's mired in science and trying to make sense of that. If you think it's difficult, you're right. In a soundbite environment, these are complicated issues."
Complicated is right. Experts often look at the same set of data and come to different conclusions about what it means. The conflicting messages lead to indecision and hurt the credibility of the health care community.
So what motivates guidelines to be issued? Groups like the U.S. Preventive Services Task Force and the National Heart, Lung, and Blood Institute issue and update guidelines after reviewing the results of trials and rating the evidence. Other groups are on a timetable to release guidelines, regardless of whether new research is available, said panelist Phil Fontanarosa, M.D., executive deputy editor of the Journal of the American Medical Association.
So even if a guideline is issued, it's often not as straightforward as some would like, particularly those of us trying to sum up the guideline in a few words for the lay public.
In the case of the USPSTF, the strength of the guideline receives a grade, from "A" (strongly recommends), "B" (recommends), "C" (no recommendation for or against), "D" (recommends against), or "I" (insufficient evidence to recommend for or against).
Fresh on everyone's mind was the reversal of the USPSTF on breast cancer screening. In November, the group changed its previous position to recommend routine mammograms for women in their 40s and gave it a "C" recommendation, that is, no recommendation at all.
"If you feel uncertain, we feel uncertain," said Lichtenfield. "I was around when the PSA (prostate specific antigen test, a screen for prostate cancer) showed up. I ordered that test and my patients got treatment based on that test. Now in 2010, we don't know if it saves lives. How do you think I feel as a physician?"
At issue in cancer screenings is the knowledge that tests – whether mammograms, Pap smears or PSA screening – detect false positives and subject patients to unnecessary biopsies, anxiety and risks. Thus, guideline authors will consider the number needed to test or treat in order to prevent a single case of disease as a factor in whether a recommendation is in order. Of course, in this age of rising health expenses, expect the cost of saving one life to be a factor as well.
So why do guidelines keep changing? Robert Bonow, M.D., of Northwestern University Feinberg School of Medicine, used an example of a boat tacking. As new studies are undertaken, evidence changes and course corrections take place. Guidelines "may change tomorrow, but only because data is stronger," he said.
Guidelines can only offer, well, guidance. After all, data from trials are only applicable to the study subjects; some patients under a doctor's care, for instance an 85-year-old heart patient with diabetes, may have been just the type of patient to be excluded from large-scale trials, Bonow noted.
"In some cases you might argue that we shouldn't have a guideline based on evidence, but that would be like having a rudderless ship," he said. "Adherence to guidelines leads to better care."
