Keys to Maneuvering Discrepancies in Clinical Practice Guidelines

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You’re listening to Living Rheum on ReachMD. On this episode, we’ll hear from Dr. Jason Busse about the current clinical practice guidelines for managing patients with chronic pain. Dr. Busse is a Professor of Anesthesia at McMaster University in Ontario, Canada, and he presented a session on this exact topic at the 2024 Congress of Clinical Rheumatology. Here’s Dr. Busse now.

Dr. Busse:

So whenever we get into topics about research, we hope that studies on the same topic will align.  If someone does a trial on a certain intervention and they do another trial and a third trial and a fourth trial, those results should all be fairly similar.  Where it becomes confusing is when people produce similar types of studies and they give very different results.  And unfortunately, we see that happening quite often with clinical practice guidelines. 

So just to give you one example, interventional procedures for chronic back pain, things such as nerve blocks, radiofrequency ablation, or epidural steroid injections, these are quite common, and they are increasing in the frequency that they are provided.  At the same time, there was a review done on 21 clinical practice guidelines last year, and the authors of the review found there was no consistency in the recommendations for or against any interventional procedure, even when accounting for the quality of the guideline.  So you can find one guideline that says these procedures are effective and should be used; you can find another guideline that says they are ineffective and should not be used.  And this makes for extremely confusing sources of information from what are supposed to be consistent evidence-based guidelines.  And so the challenge out there for patients and for prescribers is to try to sort through these different guidelines that provide discrepant recommendations to determine which ones are more trustworthy. 

Researchers need to provide better guidance to sort of help clinicians and patients sort through this, but some key points are guidelines can either be consensus based or evidence based.  Consensus based means you get a group of experts sitting around a table and they essentially decide what the recommendation will be based on their beliefs, their personal experiences, and the literature that they decide to rely upon.  An evidence-based guideline, if conducted appropriately, will have many safeguards in place to prevent any personal biases from affecting the recommendations.  And we know from a number of studies done now that consensus-based guidelines are twice as likely to make strong recommendations that violate the principles of evidence-based medicine than our evidence-based guideline, so that’s one thing to look for: Is the guideline consensus based, or is it evidence based?

The other things to look for in terms of quality of the guideline: Have they systematically reviewed the literature so that they have considered all the evidence that should be out there?  Have they appraised the quality of that literature?  Have they developed the recommendations according to a transparent and rigorous approach that includes consideration of patients’ values and preferences?  And do they provide transparency?  And by that I mean, if they have a recommendation, you can very easily trace that recommendation back to see the evidence supporting it and the values and preference statement so that it’s very clear how it was arrived at versus a guideline that maybe doesn’t do those things, and so it’s left up to the reader’s imagination how they possibly came up with it. 

The other critical issue I should mention is we are increasingly aware that conflicts of interest can play a role in the kinds of recommendations that are made by guidelines, and that conflict can either be financial if someone has a vested interest in favoring a certain intervention or product, but it can also be intellectual.  If investigators that are part of a guideline have a long history of publishing studies that are very enthusiastic about a particular treatment, it may be very difficult for them even with all the best intentions to remove their personal beliefs and biases when it comes time to make the recommendations.  So these are some of the things to look for when trying to sort between guidelines that give discrepant recommendations. 

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That was Dr. Jason Busse talking about his presentation at the 2024 Congress of Clinical Rheumatology that focused on clinical practice guidelines for chronic pain management. To access this and other episodes in our series, visit Living Rheum on ReachMD dot com, where you can Be Part of the Knowledge. Thanks for listening!