It's your call: your intuition against the experts' advice (Jan-05)

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A respected national organization has released new guidelines. As a physician, would you change your patient's treatment based on these recommendations? Imagine you are a primary care physician taking care of a male patient, Sam, with mildly elevated cholesterol. He doesn't like taking pills and, fortunately, his cholesterol has been good enough that he doesn't need any pills. But now, a respected National Organization has just revised its recommendations, and are urging doctors to treat cholesterol more aggressively, even in people like this patient, who has no history of heart disease or diabetes.

What role should these new guidelines play in your decision?

The guidelines should not be a strong consideration 1       2       3       4        5  The guidelines should be a strong consideration
What would you recommend to your patient, Sam?
I would... 
  • ask him to take a pill.
  • urge him to take a pill.
  • give him information about cholesterol and let him decide.
  • urge him not to take a pill.
  • ask him not to take a pill.

How do your answers compare?

What were some of the things you were weighing when you made your decision? Perhaps you were wondering why the National Organization would recommend taking a pill even when a patient's cholesterol is good enough that they wouldn't necessarily need the more aggressive treatment. You might have found yourself wondering whose interests were reflected in these guidelines. Did the National Organization have some kind of investment in the pill or the pharmaceutical company that produces it? You might have had some doubts about just how much you could trust the guidelines.

Resistance to practicing "cost-effective" medicine

In the past, physicians did what was best for each individual patient in their care, without having to consider cost or having to figure out whether an HMO or accreditation board was looking over their shoulders. But now physicians are put in the awkward position of having to judge whether a particular patient will benefit enough from a specific therapy for that therapy to be cost-effective. It is not surprising that physicians disparage cost-effectiveness in health care, given that traditional medical education teaches that they should not consider the cost of medical interventions when treating individual patients.

Resistance to practicing according to Clinical Practice Guidelines

Clinical practice guidelines, like the one you read about on the previous page, offer a potentially palatable way for physicians to consider the cost-effectiveness of medical interventions. High quality guidelines are based on thorough and systematic reviews of clinical and cost-effectiveness evidence. Still, physicians are often concerned that guidelines are tainted by financial conflicts of interest. The experts who are involved in writing the guidelines are often the same individuals who interact with the pharmaceutical industry.

Why cost-effectiveness and Clinical Practice Guidelines belong together

Investigator Ellen Hummel and CBDSM investigator Peter Ubel were asked by the editors of Virtual Mentor, the online ethics forum of the American Medical Association, to comment on whether clinical practice guidelines ought to incorporate cost-effectiveness information. These investigators begin by acknowledging the resistance to practicing cost-effective medicine. At the same time, however, they argue that including cost-effectiveness information in clinical practice guidelines is an essential way to address physicians' concerns about the kinds of conflicts of interest mentioned above. If cost-effectiveness evidence is presented up-front, physicians wouldn't have as many concerns that the guielines were intended to benefit the industry while sticking the patient with a higher cost. Imagine if on the previous page the guideline had presented evidence that the new, more aggressive cholesterol treatment was still well within accepted cost-effectiveness ratios despite potential conflicts of interest. You might have then better trusted the guideline's recommendation when assessing what to tell Sam.

Including cost-effectiveness information in clinical practice guidelines will enhance the credibility of their recommendations. At the same time, evidence-based guidelines help clinicians recognize the importance of practicing cost-effective medicine with their individual patients. With the help of high quality guidelines, physicians may be encouraged by groups of peers and respected authorities to restrain themselves from pursuing rare benefits for their patients, which is especially important in a time when our current health care system increasingly demands that we become involved with the costs of medical care.

Read the article:

Cost and clinical practice guidelines: Can two wrongs make it right?
Ubel PA, Hummel EK. Virtual Mentor 2004;6:np.