The Guideline Disconnect

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The guidelines, however, are usually developed by certain groups of opinion leaders and experts who are mostly, if not exclusively, academicians from renowned universities or research centers.

Many academicians spend a large proportion of their time and effort conducting research and related activities such as writing grants, developing study protocols, and writing and revising manuscripts for peer-reviewed journals.

As a result, most academicians have limited or no time for comprehensive patient care. Nevertheless, academicians design, develop, and update clinical guidelines, and private practitioners are expected to follow them.

This disconnect has implications. First, the clinical guidelines are written by those who may be least familiar with real world problems. Second, the guidelines may be biased towards certain pharmaceutical products from companies that sponsor research projects in academic centers. Third, academic ego may cloud judgment, as many academicians may refer to their own opinions and publications as sources. Fourth, practicing physicians may feel compelled to follow such guidelines to protect themselves against litigation.

 

In nephrology, a good example of this disconnect is the Kidney Disease Outcome Quality Initiative (KDOQI) guidelines. Since 1995, KDOQI guidelines have served to improve clinical outcomes of CKD patients by providing evidence-based recommendations. However, the bulk of these guidelines are based on the opinions of a number of academicians, especially because scientific evidence in many areas of CKD patient care is scarce.

 

Although KDOQI guidelines have helped increase attention to the cause of CKD across the nation and even throughout the world, they have been subject to frequent criticism for their possible bias and their relative disconnect from the real challenges of patient care.

 

A potential remedy is to invite practicing, non-academic nephrologists to contribute more to the future updating and revision of the KDOQI guidelines and to solicit funds from such governmental and non-profit agencies as the National Institutes of Health or Center for Medicare and Medicaid Services to sponsor guideline development. Such in-between guidelines should be considered as potential guidance and not firm rules.

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