Guidelines, Lighthouses, and a Toe in the Water

Artigos na �ntegra - Merck Sharp & Dohme: "Guidelines, Lighthouses, and a Toe in the Water
[Editorial]
Holmes, David R. Jr MD; Hodgson, Patricia BA; Singh, Mandeep MD
From Mayo Clinic (D.R.H., M.S.), Rochester, Minn, and Duke Clinical Research Institute (P.H.), Durham, NC.
The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.
Correspondence to Mandeep Singh, MD, Mayo Clinic, 200 First St SW, Rochester, MN 55905.
A guideline tells you how to get someplace, whereas a lighthouse keeps you off the rocks; both can shepherd you on a safe journey toward your goal. The American College of Cardiology (ACC), in concert with the American Heart Association (AHA), has been at the forefront of developing guidelines for percutaneous coronary interventions (PCI).1 In an era in which there are multiple data sets to draw from, guidelines help to sort out optimal from less optimal evidence-based approaches. Application of these guidelines makes intuitive sense as we counsel our individual patients about the risk/benefit ratio of PCI and as we develop treatment strategies for healthcare delivery systems to employ."/.../

Putting theory into practice: First survey to show that following guidelines improves outcomes
Nov 1, 2005 Lisa Nainggolan

Houston, TX - The first survey of its kind—involving more than 400 000 patients—has shown that following evidence-based guidelines for cardiac care can improve patient outcomes [1]. The results are published online before print October 31, 2005 in Circulation.

This is a reminder that guidelines can work and be useful.

"This research shows that carefully crafted guidelines can be used to improve quality of care and outcomes. This has not been shown before," lead author Dr H Vernon Anderson (University of Texas Health Science Center, Houston) commented to heartwire.

Anderson said that previous studies have revealed that adoption of effective clinical practices can be scattered, inconsistent, and haphazard, and there can be a tendency for doctors to feel "guideline fatigue" when new recommendations are issued. "But this is a reminder that guidelines can work and be useful," he stressed.

Physicians heeding guidelines
Anderson and colleagues say that the US National Cardiovascular Data Registry (NCDR) was established several years ago to provide an objective mechanism to assess guidelines-based practice. This is the first look at outcomes from the NCDR, which will be used by the American College of Cardiology/American Heart Association (ACC/AHA) Guidelines Committee to periodically reassess and revise clinical practice guidelines.

Using the NCDR, the researchers analyzed the impact of the 2001 ACC/AHA recommendations for selecting patients most likely to benefit from percutaneous coronary interventions [2]. (Procedures for ST-elevation MI were excluded.) They examined patient records from 363 hospitals during the 39 months after the 2001 guidelines were released: 412 617 patients underwent PCI and could be classified according to the recommendations.

The data show that physicians in the participating hospitals (94% community hospitals and 6% university hospitals) seemed to be heeding the guidelines when selecting patients for PCI.

Of all the procedures performed on patients, 64% were designated (according to the guidelines) as class I (medical evidence for and/or general agreement that the procedure is useful and effective) and 21% were class IIa (weight of evidence is in favor of the usefulness).

Of the PCIs, 7% of the procedures conducted were class IIb (usefulness/efficacy is less well established) and 8% were class III (medical evidence and/or general agreement that the procedure is not useful or effective and in some cases may be harmful).

Clinical success declined from almost 93% of class I procedures to 85% of class III procedures. Adverse events (MI, CABG, and death) were generally lower in the class I procedures and highest in class III procedures (with the exception of CABG in class III, which was thought by the researchers to be due to the high percentage of previous CABG in these patients).

Adherence to guidelines associated with better outcomes
The review found a relationship among procedure indications, clinical success, and adverse events, and discovered that a small number of procedures are being carried out against recommendations.

"We observed that most PCI procedures were done for class I indications and that only a small fraction were done against recommendations," the researchers say. "This finding suggests that PCI practice conforms to the guidelines to a large extent, [and] adherence to the recommended indications for PCI was associated with better outcomes.

"A more careful consideration of procedures with class IIb and III indications might improve clinical outcomes and, by extension, the quality of patient care," they note. However, they add that understanding the reasons PCIs are done against recommendations "may provide valuable clues . . . into new or developing approaches."

"Over time, the evidence and the guidelines will change, as they should, and there will always be special cases, but overall, the quality of patient care will be improved by a conscious effort to adhere to guideline recommendations," Anderson concludes.

Sources

Anderson HV, Shaw RE, Brindis RG, et al. Relationship between procedure indications and outcomes of percutaneous coronary interventions by American College of Cardiology/American Heart Association Task Force Guidelines. Circulation 2005; DOI: 10.1161/CIRCULATIONAHA.105.553727. Available at http://circ.ahajournals.org.
Smith SC Jr, Dove JT, Jacobs AK, et al. ACC/AHA guidelines of percutaneous coronary interventions (revision of the 1993 PTCA guidelines)—executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (committee to revise the 1993 guidelines for percutaneous transluminal coronary angioplasty). J Am Coll Cardiol 2001; 37:2215-2239.