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Clinical Practice Guideline
Aka: Clinical Practice Guideline, Best Practices by Specialty, Choosing Wisely Campaign, Good Clinical Practice
- Resources
- Clinical Practice Guidelines (NIH)
- https://www.nccih.nih.gov/health/providers/clinicalpractice
- National Guideline Clearinghouse (AHRQ)
- https://www.ahrq.gov/gam/index.html
- Institute of Medicine's Report Clinical Practice Guidelines We Can Trust (IOM)
- https://www.ncbi.nlm.nih.gov/books/NBK209538/
- Practice Guideline Articles (AAFP)
- https://www.aafp.org/afp/practguide
- Emergency Care Research Institute Guidelines Trust (ECRI)
- https://www.ecri.org/library/general-topics/
- Precautions: Guideline Pitfalls
- Focused Interpretation
- Guideline development focuses on improvement of specific outcomes, with less focus on other related outcomes
- Guidelines should improve patient-oriented outcomes including harms versus benefits
- Speculation
- Expert opinion is inserted when evidence is lacking
- Guidelines should be based on systematic review of the research data, and graded with strength of evidence
- Extrapolation
- Recommendations are extrapolated beyond the original research focus
- Limited Representation
- Lack of stakeholder representation in the guideline development
- Key stakeholders (e.g. specialties, patients, payers, public health) should be involved in guideline development
- Oversimplification
- Guidelines may ignore nuances of confounding factors (disease severity, age, gender, comorbidity)
- Guidelines should apply to the patient population being treated
- Over-complication
- Guidelines are too complicated to reliably implement, with exceptions and numerous sub-pathways
- Recommendations should be clear and actionable
- Economically Unfeasible
- Costs of implementation (or the conflicts of interest by developers) may not be fully addressed
- Guideline development should not be industry sponsored and free of financial conflict of interest
- References
- Barry (2022) Am Fam Physician 105(4): 350-2 [PubMed]
- Precautions: Emergency Medicine (Choosing Wisely)
- Minor Head Trauma imaging
- Avoid Head CT in minor Head Trauma when validated decision rules triage the patient to low risk
- Indwelling Urinary Catheters (Foley Catheters)
- Limit use to monitoring Urine Output in critically ill patients, urine obstruction, perioperative state and End-Of-Life Care
- Avoid indwelling Urinary Catheter in stable, voiding patients
- Not indicated for Urine Output monitoring in stable patients (void into measure container)
- Not indicated for convenience
- Palliative Care and Hospice
- Engage Palliative Care and Hospice early when indicated in chronic disease or End-Of-Life Care
- Skin Abscess management
- Avoid antibiotics and wound cultures for uncomplicated skin and Soft Tissue Abscesses
- Assumes definitive Incision and Drainage and appropriate follow-up
- Pediatric Dehydration Management
- Oral Rehydration Therapy should be the first-line intervetion in mild to moderate Pediatric Dehydration
- Intravenous replacement should be reserved for those who fail oral rehydration
- References
- http://www.choosingwisely.org/doctor-patient-lists/american-college-of-emergency-physicians/
- Precautions: Family Medicine (Choosing Wisely)
- Low Back Pain imaging
- Avoid imaging in the first 6 weeks in uncomplicated Low Back Pain without red flags
- Acute Sinusitis antibiotic management
- Avoid antibiotics in mild to moderate Acute Sinusitis until >7 days of symptoms or symptom worsening after initial improvement
- Osteoporosis Screening with DEXA Scan
- Delay DEXA Scan until age 65 years in women, 70 years in men unless Osteoporosis Risk Factors dictate otherwise
- Cardiac screening in asymptomatic, low risk patients
- Avoid cardiac screening (Electrocardiogram, stress test) in asymptomatic, low risk patients
- Cervical Cancer Screening indications (Pap Smear and HPV screening)
- Avoid Pap Smear in women under age 21 years or following Hysterectomy for benign cause
- Avoid Pap Smear in women over age 65 years who had prior adequate prior screening and not high risk for Cervical Cancer
- Avoid HPV screening (with or without cytology) in women under age 30 years
- Labor Induction and Cesarean Section scheduling
- Avoid scheduled Labor Induction or C-Section prior to 39 weeks unless medically indicated
- Carotid Stenosis screening
- Avoid Carotid Artery Stenosis screening in asymptomatic patients
- Otitis Media antibiotics
- Observation is the preferred protocol in children ages 2-12 years with non-severe Otitis Media symptoms, and other observation criteria met
- Pediatric UTI imaging
- Avoid Voiding Cystourethrogram (VCUG) in children ages 2-24 months, with first febrile Urinary Tract Infection (UTI)
- Prostate Cancer Screening
- Avoid universal Prostate Cancer Screening with Prostate-specific Antigen (PSA) test or Digital Rectal Exam
- Prostate Cancer Screening when performed should be accompanied by Informed Consent of risks and benefits
- Scoliosis Screening
- Avoid screening asymptomatic teens for Idiopathic Scoliosis
- Oral Contraceptive Prescribing
- Blood Pressure measurements and medical history alone are sufficient to provide Oral Contraceptive prescriptions
- Avoid requiring pelvic exam or physical exam prior to writing for Oral Contraceptive medications
- References
- http://www.choosingwisely.org/doctor-patient-lists/american-academy-of-family-physicians/
- Resources
- ABIM Choosing Wisely Site
- http://www.choosingwisely.org/doctor-patient-lists/