Treatment guidelines pros and cons

I was puzzled by a Health Affairs article showing the public finds arguments against treatment guidelines a lot more compelling than arguments in favor. But after reading the technical appendix, which contains the full text of the survey, I think the problem is that the researchers framed the question poorly. In particular, the researchers portrayed guidelines as unrealistically rigid.

In A National Survey Reveals Public Skepticism About Research-Based Treatment Guidelines, Gerber et al. asked respondents to rate their level of agreement with arguments for and against the use of guidelines.

Arguments for guidelines (in order of percentage of respondents finding them convincing) include:

  • Doctors have economic incentives to provide inappropriate care
  • Following guidelines will improve care for most patients
  • Doctors don’t keep up with the literature
  • Doctors are unaware of better approaches followed elsewhere

Con arguments (also ordered by percentage of respondents finding them convincing) are:

  • No outside group should come between doctors and patients
  • Doctors will be unable to tailor care to needs of individual patients
  • Guidelines are vulnerable to abuse and corruption
  • Payers will use guidelines to control costs and ration care
  • Guidelines can’t keep up with pace of medical innovation

About half or more of respondents found the average “pro” argument convincing while close to 80 percent felt that way about the “con” arguments. That’s discouraging to people like me who think guidelines are useful. But what caught me by surprise is that even though most people were concerned that doctors provided inappropriate care due to economic incentives and that guidelines would improve care for most people, they came out so strongly in favor of preventing an “outside group” from issuing guidelines and were so concerned that guidelines would prevent tailoring.

However, once I read in the technical appendix how the question was posed I could understand the results. In fact I would have answered the “con” questions similarly to the typical respondent. Here’s the wording:

Some people have proposed establishing an outside group to develop national treatment guidelines based on the latest scientific evidence. Doctors would be required to follow these guidelines when they treat patients. The government and insurance companies would refuse to pay for any treatments not supported by the guidelines even if a doctor thinks this treatment is best for their patient.

The researchers themselves included the emphasis on the words “even if a doctor thinks this treatment is best for their patient.” Instead, I think the researchers should have replaced the italicized words with, “unless a physician documents why this treatment is best for their patient.” Payers do tend to base payments on adherence to guidelines, but there is generally a lot more wiggle room than the authors imply. The authors’ wording certainly explains why people would be convinced that doctors would not be able to tailor treatment!

What the researchers call “guidelines” are more like mandated treatment pathways.

More appropriate wording about guidelines would probably shift results toward the “for” arguments.

David E. Williams is co-founder of MedPharma Partners and blogs at the Health Business Blog.

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