The Future of Medical Guidelines: Standardizing Clinical Care With the Humility of Uncertainty
Authors: Brad Spellberg, William F. Wright, Terry Shaneyfelt, Robert M. Centor
Journal: Annals of Internal Medicine (2021)

Ideas and OpinionsDecember 2021The Future of Medical Guidelines: Standardizing Clinical Care With the Humility of UncertaintyBrad Spellberg, MD, William F. Wright, DO, MPH, Terry Shaneyfelt, MD, MPH, and Robert M. Centor, MDBrad Spellberg, MDLos Angeles County + University of Southern California Medical Center, Los Angeles, California (B.S.), William F. Wright, DO, MPHDepartment of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland (W.F.W.), Terry Shaneyfelt, MD, MPHDepartment of Medicine, University of Alabama Medical Center, and Birmingham Veterans Affairs Medical Center, Birmingham, Alabama (T.S., R.M.C.)., and Robert M. Centor, MDDepartment of Medicine, University of Alabama Medical Center, and Birmingham Veterans Affairs Medical Center, Birmingham, Alabama (T.S., R.M.C.).Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M21-3034 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical guidelines seek to standardize care to increase adoption of proven superior interventions and reduce ineffective, unsafe, or wasteful practices (1). Many guidelines provide separate ratings for strength of evidence and strength of recommendation, with no requirement that these strengths match. Other guidelines may not describe the strength of evidence used as a basis for recommendations. Studies of guidelines unfortunately have reported a high proportion of recommendations—including strong recommendations—based on evidence that is low quality and hypothesis generating rather than high quality and hypothesis confirming (such as reproducible, prospective, controlled trials) (2, 3). We and others have questioned the validity ...References1. Institute of Medicine (US) Committee on Standards for Developing Trustworthy Clinical Practice Guidelines. Clinical Practice Guidelines We Can Trust. National Academies Pr; 2011. Google Scholar2. Shaneyfelt TM, Centor RM. Reassessment of clinical practice guidelines: go gently into that good night [Editorial]. JAMA. 2009;301:868-9. [PMID: 19244197] doi:10.1001/jama.2009.225 CrossrefMedlineGoogle Scholar3. Miles KE, Rodriguez R, Gross AE, et al. Strength of recommendation and quality of evidence for recommendations in current Infectious Diseases Society of America guidelines. Open Forum Infect Dis. 2021;8:ofab033. [PMID: 33614818] doi:10.1093/ofid/ofab033 CrossrefMedlineGoogle Scholar4. Wright WF, Jorgensen SCJ, Spellberg B. Heaping the Pelion of vancomycin on the Ossa of methicillin-resistant Staphylococcus aureus: back to basics in clinical care and guidelines [Editorial]. Clin Infect Dis. 2021;72:e682-4. [PMID: 32901250] doi:10.1093/cid/ciaa1360 CrossrefMedlineGoogle Scholar5. Chlebowski RT, Hendrix SL, Langer RD, et al; WHI Investigators. Influence of estrogen plus progestin on breast cancer and mammography in healthy postmenopausal women: the Women's Health Initiative randomized trial. JAMA. 2003;289:3243-53. [PMID: 12824205] CrossrefMedlineGoogle Scholar6. Baghdadi JD, Brook RH, Uslan DZ, et al. Association of a care bundle for early sepsis management with mortality among patients with hospital-onset or community-onset sepsis. JAMA Intern Med. 2020;180:707-16. [PMID: 32250412] doi:10.1001/jamainternmed.2020.0183 CrossrefMedlineGoogle Scholar7. Barbash IJ, Davis BS, Yabes JG, et al. Treatment patterns and clinical outcomes after the introduction of the Medicare Sepsis Performance Measure (SEP-1). Ann Intern Med. 2021;174:927-35. [PMID: 33872042] doi:10.7326/M20-5043 LinkGoogle Scholar8. Guallar E, Laine C. Controversy over clinical guidelines: listen to the evidence, not the noise [Editorial]. Ann Intern Med. 2014;160:361-2. [PMID: 24473997] doi:10.7326/M14-0112 LinkGoogle Scholar9. Doherty R, Cooney TG, Mire RD, et al; Health and Public Policy Committee and Medical Practice and Quality Committee of the American College of Physicians. Envisioning a better U.S. health care system for all: a call to action by the American College of Physicians. Ann Intern Med. 2020;172:S3-6. [PMID: 31958804] doi:10.7326/M19-2411 LinkGoogle Scholar10. Qaseem A, Yost J, Forciea MA, et al; Scientific Medical Policy Committee of the American College of Physicians. The development of living, rapid practice points: summary of methods from the Scientific Medical Policy Committee of the American College of Physicians. Ann Intern Med. 2021;174:1126-32. [PMID: 34029483] doi:10.7326/M20-7641 LinkGoogle Scholar Author, Article, and Disclosure InformationAffiliations: Los Angeles County + University of Southern California Medical Center, Los Angeles, California (B.S.)Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland (W.F.W.)Department of Medicine, University of Alabama Medical Center, and Birmingham Veterans Affairs Medical Center, Birmingham, Alabama (T.S., R.M.C.).Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M21-3034.Corresponding Author: Brad Spellberg, MD, 2051 Marengo Street, C2K122, Los Angeles, CA 90033; e-mail, [email protected]lacounty.gov.Author Contributions: Conception and design: B. Spellberg, W.F. Wright, T. Shaneyfelt, R.M. Centor.Analysis and interpretation of the data: W.F. Wright, R.M. Centor.Drafting of the article: B. Spellberg, W.F. Wright, T. Shaneyfelt, R.M. Centor.Critical revision of the article for important intellectual content: B. Spellberg, W.F. Wright, T. Shaneyfelt, R.M. Centor.Final approval of the article: B. Spellberg, W.F. Wright, T. Shaneyfelt, R.M. Centor.Administrative, technical, or logistic support: B. Spellberg, R.M. Centor.Collection and assembly of data: W.F. Wright.This article was published at Annals.org on 16 November 2021. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAnnals On Call - Guidelines With Humility Robert M. Centor , Brad Spellberg , and Terry Shaneyfelt Metrics Cited byOpinion-Based Recommendations: Beware the Tyranny of Experts December 2021Volume 174, Issue 12Page: 1740-1742KeywordsClinical trialsHealth careHealth care providersHematology and oncologyHospital medicineInpatientsRetrospective studiesSub-specialty careTreatment guidelines ePublished: 16 November 2021 Issue Published: December 2021 Copyright & PermissionsCopyright © 2021 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...