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Rheumatology 2001; 40: 841-842
© 2001 British Society for Rheumatology
Editorial |
From protocols to principles, from guidelines to toolboxes: aids to good management of osteoarthritis
MRC Health Services Collaboration, Department of Social Medicine, University of Bristol, Canynge Hall, Whiteladies Road, Bristol, BS8 2PR, UK The Department of Social Medicine at the University of Bristol is the lead centre of the MRC HSRC.
The recent publication of six new, but rather different, guides to the treatment of osteoarthritis (OA) [1–6] has stimulated this editorial, which asks the question ‘what is a treatment guideline for?’ It concludes that there are probably many alternatives that might be of more value to both patients and health care practitioners.
Guidelines are supposed to ‘assist practitioners and patients about appropriate health care for specific clinical circumstances’ [7]. They are also supposed to be systematically developed and evidence-based, as they have arisen directly from the evidence-based health care movement [8].
In fact they are generally used for quite different purposes, including quality assurance, cost control and the reduction of practice variations. To these ends, guideline developers are increasingly looking to find ways of implementing their recommendations—in other words imposing their guideline so that variations are reduced, quality is improved or costs controlled [9].
None of this is of any help to the individual patient or practitioner. It is not surprising, therefore, to find that guidelines are difficult to implement and that they have very little impact [10]. Perhaps it is time we thought of different ways of making treatment choices easier and more rational for patients and practitioners.
Guidelines sit in the middle of a hierarchy of levels of evidence-based ‘advice and instruction’ to practitioners and patients—this hierarchy mirrors that of the evidence base itself, as shown in Fig. 1
. At the top of the evidence base comes the randomized controlled trial and at the bottom the clinical anecdote. At the top of the equivalent advice hierarchy is the clinical protocol and at the bottom comes the expert's recommendation. They move from the most authoritarian approach, beloved by the present government (e.g. NICE protocols), to the least directive approach (the recommendation that says ‘this is what I would do’).
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The recent set of publications on the treatment of OA illustrate the differences in hierarchies of advice. NICE have provided us with referral guidelines [1], which come close to being protocols—in other words they tell us what to do. As protocols have little to do with the real world of individual variations in need and priorities, they are unlikely to be used much, or to help a lot. The Cochrane Library contains some authoritative reviews of the evidence base as it pertains to certain specific issues relating to OA management. For example, the review of non-aspirin, non-steroidal anti-inflammatory drugs for hip OA [11], and the recent review of low level laser therapy in the treatment of OA [12]. These reviews provide us with the best evidence, but are concentrated on tiny parts of the overall jigsaw of treatment options, and presented in an indigestible form. The British Medical Journal publication [2] uses these systematic reviews and other evidence-based sources to provide an overview of the evidence relating to specific, commonly asked treatment questions (such as ‘are non-steroidal anti-inflammatory drugs better than simple analgesics?’), and is more user-friendly than the Cochrane reviews. The EULAR guidelines [3] provide us with a systematic review of all the evidence on the treatment of OA of the knee, and derive effect sizes for different interventions, as well as comments on the strength of the evidence. The ACR guidelines provide consensus opinion statements on the use of some of these therapies, in addition to evidence-based conclusions on OA management [4]. The PCR have provided us with an approach which is nearer the bottom of the hierarchy, being largely based on opinion, but giving simple, straightforward and user-friendly advice [5].
There are major problems with each of these approaches:
- (1) The evidence base is constrained by the areas in which there is existing evidence, and there is ‘evidence’ that this is distorted by several biases [13].
- (2) All evidence-based approaches are aimed at the ‘average’ patient and are based on aggregate data—they give results like NNTs (number needed to treat) or NNHs (number needed to harm), which do not help at all when it comes to treating individual patients.
- (3) The opinions included in some of the guidelines are offered by small numbers of physicians, and do not include the views of other important stakeholders in the management of OA, such as therapists and patients [14].
- (2) All evidence-based approaches are aimed at the ‘average’ patient and are based on aggregate data—they give results like NNTs (number needed to treat) or NNHs (number needed to harm), which do not help at all when it comes to treating individual patients.
What health care professionals and patients need is help with the individual problem. Nobody is average and each individual with any given condition is likely to have different needs and priorities.
Medicine is about ‘clinical judgement’—in other words making decisions for or with patients that are right for them, but which are necessarily based on inadequate evidence. If the evidence could tell us what to do, then protocols would be right for everyone, and we would not need professionals such as doctors.
It is obvious that we need to know what evidence exists, and to incorporate it into our shared decision making with individuals. No health care professional can keep up with all the literature, so we need help in this. But current protocols and evidence-based guidelines miss the mark for reasons outlined above, and, as mentioned, are largely being used for quite separate, political agendas, rather than to improve the quality of care for individuals.
There must be a better way. I would suggest two different approaches: (1) a move from protocols to statements of principles; (2) a move from guidelines to the provision of ‘toolboxes’ (or options) for both patients and professionals.
- (1) As clinical judgement means relating the evidence to individuals, the overriding need is to understand the basic principles on which decisions should be made. For example, in the case of the management of OA, all stakeholders might agree that one overriding principle should be that someone with severe pain and disability should have the option of a joint replacement.
- (2) Guidelines are too constrained to be useful in the management of chronic, heterogeneous disorders like OA. A better alternative is to lay out the options available, with simple statements on the strengths and weaknesses of each, that can be understood by patients as well as professionals. The ‘Renovare’ toolbox attempts to provide such an aid to the management of OA [6].
- (2) Guidelines are too constrained to be useful in the management of chronic, heterogeneous disorders like OA. A better alternative is to lay out the options available, with simple statements on the strengths and weaknesses of each, that can be understood by patients as well as professionals. The ‘Renovare’ toolbox attempts to provide such an aid to the management of OA [6].
References
- NICE guidelines for referral of patients with osteoarthritis. London: National Institute for Clinical Excellence, 2000.
- Dieppe P, Chard J, Faulkner A, Lohmander S. Osteoarthritis. In: Clinical evidence, Vol. 4. London: BMJ Publishers, 2001:649–63.
- Pendleton A, Arden N, Dougados M et al. EULAR recommendations for the management of knee osteoarthritis. Ann Rheum Dis 2000;59:936–44.
- ACR subcommittee on osteoarthritis guidelines. Recommendations for the medical management of osteoarthritis of the hip and knee. Arthritis Rheum2000;43:1905–15.[ISI][Medline]
- Dickson J, Hosie G. Managing osteoarthritis in primary care. Oxford: Blackwell Science Publishers.
- Lohmander S, Dieppe P, Croft P. Knee pain and osteoarthritis: a management aid. Renovare initiative, 2000.
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Cook DJ, Greengold NL, Ellrod G et al. The relation between systematic reviews and practice guidelines. Ann Intern Med1997;127:210–6.
[Abstract/Free Full Text] - Woolf SH. Practice guidelines: a new reality in medicine. Arch Intern Med1990;150:1811–8.[Abstract]
- Baker R. Is it time to review the idea of compliance with guidelines? Br J Gen Pract2001;51:7.[Medline]
- NHS centre for reviews and dissemination. Getting evidence into practice. Eff Health Care1999;5:1–18.
- Towheed T, Shea B, Wells G, Hochberg M. Analgesia and non-aspirin, non-steroidal anti-inflammatory drugs for osteoarthritis of the hip (Cochrane Review). Cochrane Library, 1997.
- Brousseau L, Welch V, Wells G et al. Low level laser therapy for treating osteoarthritis (Cochrane Review). Cochrane Library, 2000.
- Tallon D, Chard J, Dieppe P. Relation between agendas of the research community and the research consumer. Lancet2000;355:2037–40.[ISI][Medline]
- Tallon D, Chard J, Dieppe P. Exploring the priorities of patients with osteoarthritis of the knee. Arthritis Care Res2000;13:312–9.
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