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- Page navigation anchor for RE: Guideline groups should make recommendations even if the evidence is considered insufficientRE: Guideline groups should make recommendations even if the evidence is considered insufficient
This commentary is all about how physicians should respond to uncertainty; and I would strongly disagree with the approach advocated by the authors. They point to evidence that physicians are uncomfortable with uncertainty and wish someone would just tell them what to do. Fair enough, but uncertainty will not go away just because we don't like it. Graded recommendations based on the strength of available evidence and the magnitude of benefit are what we need from guidelines. When enough uncertainty exists that no one really knows what to do, then we should admit that. It is easily plausible that guideline recommendations based on expert opinion alone could standardize care without providing any benefit. They could also make it harder to obtain evidence. If surgery X is the standard of care despite very poor quality evidence then it will be harder to convince ethics boards that it is reasonable to withhold surgery X from a control group. Physicians already struggle with the concept that guidelines contain both strong and weak evidence based recommendations. Let us not confuse them further by adding more consensus based recommendations. When the evidence is strong we should use it to standardize practice, when it is very weak there is no benefit to standardization. If physicians want suggestions on what to do in the face of uncertainty then they can look to narrative reviews. Uncertainty is part of life and pretending otherwise is not healthy for the medical community....
Show MoreCompeting Interests: None declared.References
- Ignacio Neumann, Holger J. Schünemann. Guideline groups should make recommendations even if the evidence is considered insufficient. CMAJ 2020;192:E23-E24.
- Page navigation anchor for RE: Guideline groups should make recommendations even if the evidence is considered insufficientRE: Guideline groups should make recommendations even if the evidence is considered insufficient
I read with great interest the article by Neumann and Schünemann,(1) and agree with their commentary. Evidence-based medicine has been a remarkable and positive revolution in medicine, but one unintended consequence has been the reluctance to make recommendations or develop guidelines when little or no high-quality evidence is available.
Clinicians involved in the development of guidelines are generally experts within their fields, and other physicians would benefit from their expert consensus on specific management challenges, which likely reflects their real-world practices. This is especially true for low-risk and non-invasive interventions (e.g. cardiac testing for certain inherited conditions). Additionally, in many rare diseases, randomized trials will not be performed, nor will high quality evidence be forthcoming in the immediate future. In these situations, the lack of expert-consensus recommendations risks perpetuating non-uniform management, with potential impacts on quality of care. In areas lacking high quality evidence, other methodologies could be used to increase the rigor of recommendations, such as the Rand/UCLA Appropriateness Method.(2) This method can be time-consuming, but has been used effectively in some fields.(3) Of course, recommendations created in this fashion would have to be marked as being based upon a lower level of evidence, but this would be better than simply making no recommendation at all. As the authors correctly point out, th...
Show MoreCompeting Interests: None declared.