Recent articles in the Journal of the American Medical Association (here1 and here2) reported on the use and misuse of clinical practice guidelines, and the need to avoid hedging and equivocation when writing them.
These articles also discussed the differences inherent in targeting individual physician decision support versus more general purposes, as well as issues related to lack of adherence to guideline development standards published by the Institute of Medicine3.
A related issue is that it is not uncommon for guidelines developed by different specialty societies to advocate different approaches to a given clinical situation. This inter-guideline lack of alignment is another source of ambiguity and confusion.
The bottom line is that a broadly representative guideline development team, with expertise in evidence-based clinical development methodology, is crucial to guideline development and adoption, and that guideline precision and specificity matter. Guidelines with ambiguous, hedged, or equivocal recommendations aren’t really guidelines at all.
Further, guidelines developed without multispecialty and multidisciplinary input are likely to be seen as biased in favor of the single specialty or discipline that developed them, especially if there are potential conflicts of interest, disclosed or undisclosed, for any developers.
These problems were pointed out by the Institute of Medicine in their landmark 2011 publication, Clinical Practice Guidelines We Can Trust3, which proposed eight standards around transparency, conflict of interest, development group composition, the use of systematic reviews, evidence evaluation and recommendation strength, recommendation clarity, external review, and the updating process.
These conclusions and standards are directly relevant to clinical criteria, including our own InterQual. Clinical criteria should be as specific, objective, and unambiguous as possible. Clinicians at the point of care and nurses performing utilization management reviews should not have to “fill in the blank” or be puzzled by subjective terms such as “severe.” Rather, they should have access to specific, objective findings that help them make fast, appropriate care decisions.
For example, it’s easy to disagree on what “mild hypoxia” means. On the other hand, an oxygen saturation of 89%-92% is not subject to interpretation. This precision should be the goal to help ensure timely, appropriate care, as well as to help avoid denials, appeals, and unnecessary work for both providers and payers because of incomplete, unclear, or otherwise less-than-ideal documentation.
Striving for and providing specificity reduces unwarranted variability in review outcomes for a given patient reviewed by multiple nurses, or for many patients with similar presentations reviewed by a single nurse. Consistent review outcomes are quality outcomes. Moreover, reviews using clear, objective criteria with a shared clinical vocabulary foster accurate communication between payers and providers.
1 Greenfield S. Clinical practice guidelines: Expanded use and misuse. JAMA. 2017;317(6):594-595.
2 Klasco RS, Glinert LH. Language for actionable recommendations in clinical guidelines: Avoiding hedging and equivocation. JAMA. 2017; 317(6):583-584.
3 Greenfield S, Steinberg EP, Auerbach A, Avorn J, Galvin R, Gibbons R, et al. Clinical practice guidelines we can trust. Washington, DC: Institute of Medicine; 2011