Do Clinical Guidelines Still Make Sense? Yes

The subject of this Point / Counterpoint is the future of clinical practice guidelines. Does it still make sense to devote resources to creating them? Poor adherence is the principal argument against guidelines. Two articles in this issue show low rates of adherence to guidelines for statins and asthma, respectively.1,2 While its premise is true, the poor adherence argument ignores the good that guidelines do. First, they represent a profession’s best efforts to define its standard of practice. Second, health insurance companies use guidelines to help decide their coverage policies. Third, guidelines are the basis for practice measures, which do influence clinical practice.3 Fourth, the systematic reviews that serve as the basis for practice guidelines are a public good. For these reasons, although practice guidelines have a bright future, they need fixing. I address 3 questions. How can we increase public trust in guidelines? How can we make guidelines more transparent to the public? What is the role of practice guidelines in the era of shared decision making? What is a practice guideline? The 2010 Institute of Medicine (IOM) study entitled “Practice Guidelines That We Can Trust”4 defined them as follows: “Clinical practice guidelines are statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.” This definition states the aim of guidelines—to optimize care—and identifies 2 process elements as so fundamental that a guideline without them is not to be trusted. The first, a systematic review, is an unbiased method for describing a body of evidence. The second, the difference between benefits and harms (the net benefit), is a strong rationale for choosing the option with the largest net benefit.