The numerous and frequently contradictory guidelines for the health services need to be tidied up. Who will take charge of medical knowledge?
Photo: Einar Nilsen
«Are the authorities now exercising stronger governance over medical knowledge?» This question was raised by Åsmund Reikvam in an editorial in the Journal of the Norwegian Medical Association in 2007 (1). Nine years later, the answer seems to be yes. On the website «National medical guidelines», maintained by the Directorate of Health, we can now find 50 sets of guidelines and more than 90 government manuals (2). If we also include guidelines for setting of priorities and the package solutions for cancer patients on the same web page, more than 200 different documents are collected here that in various ways describe what health personnel should and should not do in clinical practice. Even though the Directorate of Health in recent years has tightened the requirements for its own guidelines, it is frequently difficult to tell the difference between these and the various «manuals» that are found on the same web page and also provide instructions for diagnostics and treatment (2).
The Directorate of Health is far from the only actor in this area. The specialty associations of the Norwegian Medical Association are to a varying degree active in preparing their own guidelines and manuals. No centralised overview of these is available. Some of them are published on the specialty associations’ own websites, others are available on paper or as PDF files. Some coincide with the national manuals from the Directorate of Health, others are based on international guidelines or consensus reports, while others again are prepared on the basis of a national consensus with no systematic weighting of literature or thorough assessment of the authors’ impartiality or conflicts of interest.
Moreover, there are yet more actors in the guidelines market. Some sub-specialties outside the specialty associations have prepared their own guidelines, and the methodologies vary here as well. In addition, there are electronic decision support systems such as the Norwegian Electronic Medical Handbook (3) and UptoDate (4). Both of these are widely used and provide clear instructions for diagnostics and treatment. To add to the confusion, a number of hospitals and health enterprises often have their own methodology handbooks, most of which have been prepared locally. Some of them are specific to specialities, others are specific to departments. No centralised overview is available. The recommendations provided by such methodology handbooks will often describe the same clinical issues as the guidelines produced by the authorities and the innumerable specialty associations.
Quite often it transpires that this forest of competing guidelines presents a practical problem to clinicians, especially when the governmental instructions collide head-on with the opinions of the specialty associations. Then, the debate quickly heats up (1, 5 – 7).
This problem is not particular to Norway. In the USA, more than ten mutually contradictory guidelines for the prevention of urinary tract infections associated with the use of catheters have been registered (8). The American National Guideline Clearinghouse was established in the 1990s by the authorities and the medical association jointly, with the objective of collecting all relevant clinical guidelines. In 2014, the website contained more than 2 500 of them, and had to tighten its criteria in order to maintain its credibility (9).
However, the fact that a growing number of guidelines appear to be contradictory is not the only paradox of this development. Methods that detect differences at the group level, such as the classic randomised, controlled study, are ranked uppermost in the knowledge hierarchy. When guidelines are increasingly based on such studies, they increasingly favour the fictitious average patient. At the same time, there is a development towards individualisation of treatment – individually adapted medicine (10). This renders guidelines based on group data rather unhelpful.
In a similar paradox, guidelines are almost exclusively based on specific diseases and on knowledge from large, randomised studies, in which multimorbidity tends to be an exclusion criterion. However, the population is ageing and patients are thus increasingly multimorbid. While accumulating a greater number of increasingly detailed guidelines for clinical practice, we thus risk that their relevance diminishes. At worst, they may be harmful for a considerable number of patients (11). Future guidelines need to take this into account as well.
The confusion of guidelines that in the meanwhile continues to prevail for the average clinician is paralleled by the chaotic organisation of the guidelines website of the Directorate of Health. In its alphabetical topsy-turvy system, the guidelines for treatment of oesophageal cancer are flanked by the recommendations for infant nutrition and the manual for noise assessment in construction of community installations respectively (2). Some are available as PDF files, others as HTML. Some were updated in 2008, others in 2016. If the government authorities wish to exercise stronger governance, this could be a suitable place to start the clean-up. Or perhaps the doctors’ own organisations could rally to take charge of medical knowledge in a clearer and more consistent manner?