Chapter 003. Decision-Making in Clinical Medicine (Part 11)

Chapter 003. Decision-Making in Clinical Medicine (Part 11)

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Clinical Practice Guidelines According to the 1990 Institute of Medicine definition, clinical practice guidelines are "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances." This definition provides emphasis to several crucial features of modern guideline development. First, guidelines are created using the tools of EBM. In particular, the core of the development process is a systematic literature search followed by a review of the relevant peer-reviewed literature. Second, guidelines are usually focused around a clinical disorder (e.g., adult diabetes, stable angina pectoris) or a health care intervention (e.g., cancer screening). ...

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Chapter 003. in Clinical Medicine (Part 11) Practice to the 1990 Institute of Medicine clinical practice are developed to assist and patient decisions about health care for specific clinical This provides emphasis to several crucial features of modern guideline First, are created using the tools of EBM. In the core of the process is a search followed by a review of the relevant Second, are usually focused around a clinical disorder (e.g., adult diabetes, stable angina pectoris) or a health care (e.g., cancer Third, are intended to not to define what decisions should be made in a The primary objective is to improve the quality of medical care by areas where care should be based on are narrative documents by an expert panel whose is often chosen by These panels vary in the degree to which they represent all relevant The guideline consist of a series of specific a summary of the quantity and quality of evidence each and a narrative of the Many have little or no evidence and, thus, reflect the expert of the guideline panel. In part to protect against errors by panels, the final step in guideline is peer review, followed by a final in response to the critiques provided. are closely tied to the process of quality in through their of best Such can be used as quality Examples include the of acute MI patients who receive aspirin upon admission to a hospital and the of patients with depressed ejection fraction who are on an ACE Routine and reporting of such quality can selective in quality, since many prefer not to be In this era of EBM, it is tempting to think that all the difficult decisions face have been or soon will be solved and digested into practice and However, EBM provides with an ideal rather than a finished set of tools with which to manage patients. The of EBM has been to promote the of more and EBM tools that can be accessed by the busy This is an important that is slowly changing the way medicine is One of the repeated of EBM pioneers has been to replace reliance on the local expert" (who may be often wrong but is rarely in doubt) with a search for and of the But EBM has not the need for Each review or clinical practice guideline presents the of whose biases remain largely invisible to the review's In cannot generate evidence where there are no adequate trials, and most of what confront in practice will never be tested in a trial. For the future, excellent reasoning skills and by tools and a keen for patient will to be of paramount in the life of medical Further Readings Balk EM et al: of quality measures with estimates of treatment effect in of trials. JAMA 287:2973, 2002 [PMID: 12052127] Del Mar C et al: Clinical Thinking: Evidence, and Making. Malden, Mass., 2006 Grimes DA et al: Refining clinical diagnosis with ratios. Lancet 2005 [PMID: 15850636] Haynes RB et al: Clinical How to Do Clinical Practice Williams & Wilkins, 2006 ED et al: between hospital process and among patients with acute coronary syndromes JAMA 295:1912, 2006 [PMID: 16639050] BM et al: clinical research into clinical practice: Impact of using rules to make Ann Intern Med 144:201, 2006 [PMID: 16461965] Sanders GD et al: of screening for HIV in the era of highly active therapy. N Engl J Med 352:570, 2005 [PMID: