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Clinical Practice Guidelines Should Include Patient’s Preferences

February 2014 Vol 7, No 1, Special Issue ASH 2013 Payers' Perspectives in Oncology

Clinicians want to provide excellent patient care, without having to appraise every new study in their field, but producing the “authoritative, instructive resource for most clinical scenarios” is not as straightforward as it would seem, according to David A. Garcia, MD, Professor of Medicine, University of Washington School of Medicine, Seattle.

At a symposium on quality care and clinical practice guidelines, Dr Garcia emphasized the need to include the preferences of patients, whose lives are impacted by these guidelines.

“Our job is to apply evidence and guideline recommendations within the context of individual patient preferences and values, and these can never be predicted or accounted for by people writing the guidelines,” he said.

Consider the Patient
The best guidelines are based on “strong evidence,” and the proper ingredients of a “strong recommendation” are 2-fold: (1) the inclusion of high-quality evidence that proves the impact on important clinical outcomes, as opposed to surrogate outcomes that may not matter to the patient, and (2) the demonstration that any risks associated with the intervention are clearly outweighed by the benefits, Dr Garcia said.

“These seem obvious, but as physicians, we may not always predict accurately what the patient sees as being worthwhile, in terms of the risks they are willing to accept for the benefits we can offer,” he noted.

Future guideline writers need to focus on patient-important (not surrogate) outcomes whenever possible, Dr Garcia suggested, and to be equipped with better knowledge about how patients view the trade-offs associated with treatment options.

Dr Garcia suggested the following proposals for guideline developers:
  • Minimize conflicts of interest but still harness the expertise held by “conflicted” individuals; this can be controlled by limiting the power of those with conflicts of interest
  • Focus on patient-important outcomes
  • Consider trade-offs from the patient’s perspective
  • Maintain transparency regarding the evidence and methods used to create the guideline, as well as any possible conflicts of interest
  • Provide key recommendations as in synthesis form that can be used at the bedside: a summary, checklist, algorithm—with strength clearly labeled.
Last modified: August 30, 2021