Can conflicting guidelines be good for patients?

After I left my position as a staffer for the U.S. Preventive Services Task Force in November 2010, it was three years before I was tapped for another guideline post, this time at the American Academy of Family Physicians. Recently I joined the AAFP’s Commission on Health of the Public and Science, which formulates guidance for family physicians on a variety of topics, including clinical preventive services. My appointment coincided with the release of two high-profile guidelines on high blood pressure and cholesterol.

For most of my career in family medicine, nearly all physicians followed the same guidelines to manage these common risk factors for cardiovascular disease: JNC 7 and ATP 3, expert panels convened by the U.S. National Heart, Lung, and Blood Institute. After the JNC 7 blood pressure guideline was published in 2003, waiting for the release of the next iterations of these guidelines was like waiting for Godot. Then, in an abrupt move that was seen by some as wanting to avoid a public uproar similar to that caused by the 2009 USPSTF guideline on mammography, the NHLBI announced last year that it would no longer sponsor guideline development, and instead leave the process of translating evidence into recommendations to professional medical societies.

The result has been a fracturing of the longstanding primary care and subspecialist consensus on what to do for patients with high blood pressure and cholesterol. The new cholesterol guideline, published under the auspices of the American College of Cardiology and American Heart Association, quickly came under fire for recommending that clinicians base treatment decisions on a new cardiovascular risk calculator that could lead to a surge in statin prescriptions for older adults with normal cholesterol levels.

In contrast, the hypertension panel elected to skip organizational endorsement and publish their guideline directly in JAMA. JNC 8 endorsed looser blood pressure targets for older adults and rejected stricter targets for adults with diabetes and chronic kidney disease. Dissension within the panel became public when five members published a minority report that argued against abandoning the goal of a systolic blood pressure under 140 in older adults. As of this writing, it’s not clear which medical groups will decide to endorse or reject the new guidelines.

There has been much hand-wringing about the potential negative impact of conflicting guidelines. Whose guideline should doctors follow? How do we explain to our patients why guideline recommendations differ? When I worked for the federal government, these kinds of concerns engendered not-so-subtle pressure to harmonize or align existing discrepancies between official guidelines, such as those on screening for HIV and hepatitis B and C.

Now, the USPSTF and the Centers for Disease Control and Prevention concur on whom to screen for these infections, but to align their new recommendations, the Task Force arguably lowered its evidence bar and drew conclusions from a weak literature base. The same thing seems to have happened in lung cancer screening, where USPSTF recommendations for annual CT scans in heavy smokers harmonized with guidelines from oncology and pulmonology groups but were later rejected for “insufficient evidence” by the AAFP (though I agree, I was not involved in the AAFP’s decision process).

Sure, it’s easier for everyone when guidelines agree on what to recommend for a particular patient in a particular situation. But when “reaching alignment” is simply a euphemism for one guideline group exerting political pressure on others to fall into line, that isn’t good for medicine or for patients. After all, it wasn’t so long ago when medical groups marched in virtual lock-step to recommend menopausal hormone therapy to reduce the risk of heart attacks and strokes, and to drive blood glucose levels as close to normal as possible in patients with type 2 diabetes. Both of these recommendations now appear to have done much more harm than good. Patients’ interests would have been better served if at least one guideline group had had the courage to get off the bandwagon.

Kenneth Lin is a family physician who blogs at Common Sense Family Doctor

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  • John C. Key MD

    I think all guidelines have the potential to be problematic, especially since they appear to have the imprimatur of “those who are in the know” rather that just being helpful suggestions for clinicians. Who is the objective arbiter, anyway? Personally I am more inclined to go with the professional societies than anything more directly tied to Big Pharma or to the Federal government. With money and influence flowing so many different ways it is hard to trust anyone implicitly.

    • Suzi Q 38

      As a former pharmaceutical rep (in my younger years), I agree.

  • disqus_question_everything

    As far as the following statement “After all, it wasn’t so long ago when medical groups marched in virtual lock-step to recommend menopausal hormone therapy to reduce the risk of heart attacks and strokes…” – The problem with this was that most women in the Women’s Health Initiative study were years past menopause when started on HRT (most in their early 60′s). A subsequent study(ies) has (have) shown that estrogen alone (without a progestin) is associated with lower calcified arterial plaque in younger post-menopausal women. And estrogen alone does not increase risk of breast cancer. Transdermal forms of estrogen do not have the clotting risks of oral forms. Too many physicians treat all HRT the same.

    But more importantly, very few women would feel the need to take HRT if it were not for the GROSS overuse of hysterectomy and oophorectomy. 76% of hysterectomies do not meet ACOG criteria and 73% of women are castrated at the time of hysterectomy. Just as a man’s prostate and testicles are essential to good health and well-being his whole life, so are a woman’s.

    So although guidelines have some usefulness if based on strong evidence, one must consider the individual patient’s circumstances as well as her/his desires. And as we have seen, many guidelines can change based on new findings.