Letter From the LipidSpin Editors: Guidelines: What Are They? What Can They Do? What Can They Not Do?

The following are some basic thoughts and information on guidelines based on my understanding.

Guidelines aim to guide decisions and criteria for diagnosis, management, and treatment. They have been around for the entire history of medicine. They are now supposed to be based on an examination of all the current evidence within the paradigm of evidenced based medicine (EBM). A healthcare provider is obliged to know the medical guidelines of his or her profession and has to decide whether or not to follow the recommendations of a guideline for an individual’s treatment.

They’re supposed to summarize and evaluate the highest quality evidence and the most current data about prevention, diagnosis, therapy, and prognosis.

Some contain decision trees. They can integrate the identified decision points and respective courses of action to assist experience of practitioners in clinical judgment. Often the objective is to standardize care, to raise the quality of care and to make it uniform, in hopes of reducing risk. There is little doubt that these objectives can be improved by using guidelines. National or international bodies produce them. Local healthcare providers may produce their own sets of guidelines or adapt them.

Guidelines can lose relevance as newer information becomes available. New information emerges and evolves now at an exponential rate. Some have found that as many as 20 percent of strong recommendations, especially when based on expert opinion, may be retracted.1  Unfortunately guidelines may not be inclusive or they may be biased on information gathering and/or assessment. They may be products of conflicts of interest. They can may make recommendations that are stronger than the supporting evidence.2 What is more important is that more than 90 percent of the clinical decisions we have to make on a daily basis are not covered by any guidelines.

The National Lipid Association (NLA) is striving to provide clinical recommendations that can act as a guide to all current evidence. By definition, the NLA cannot come up with best evidence for every given clinical scenario.

So what is a practitioner supposed to do? I submit that building skills to acquire best evidence is an individual learning pathway, and I believe the NLA will serve its members best by offering pathways toward this development.

What are the essential skills needed? First, basic clinical epidemiology and biostatistics. Second, point of service information access tools. Third, practice — participating in meetings that illustrate how to utilize best evidence in patient care management helps a lot. The art of finding best evidence, evaluating best evidence, and learning how to integrate the evidence within our patient value system and within the system of healthcare delivery we practice empowers us to deliver the best care available by optimizing our talents.

Nothing substitutes for clinical judgment. Evidence-based informed clinical judgment is the highest form of clinical judgment we can offer.

References are listed on page 33 of the PDF.