Year : 2017 | Volume
: 59 | Issue : 5 | Page : 5--6
Clinical Practice Guidelines: Principles for Clinical Practice
T.S. Sathyanarayana Rao1, Abhinav Tandon2,
1 Professor, Department of Psychiatry, JSS Medical College and Hospital, JSS University, Mysore, India
2 Asst Editor, Indian Journal of Psychiatry, Consultant Neuropsychiatrist, Dr AK Tandon Neuropsychiatric Centre, Allahabad, India
T.S. Sathyanarayana Rao
Professor, Department of Psychiatry, JSS Medical College and Hospital, JSS University, Mysore
|How to cite this article:|
Rao TS, Tandon A. Clinical Practice Guidelines: Principles for Clinical Practice.Indian J Psychiatry 2017;59:5-6
|How to cite this URL:|
Rao TS, Tandon A. Clinical Practice Guidelines: Principles for Clinical Practice. Indian J Psychiatry [serial online] 2017 [cited 2020 Sep 21 ];59:5-6
Available from: http://www.indianjpsychiatry.org/text.asp?2017/59/5/5/196967
"Principles are guidelines for human conduct that are proven to have enduring, permanent value."--- Stephen Covey
A revision of the clinical practice guidelines (CPGs) by Indian Psychiatric Society(IPS) was long overdue, considering the intensity and momentum of current research in Neurosciences. This daunting task was taken up and completed by an expert group of academicians, after an initial online survey and later taking into consideration the opinion of the members of IPS, through open suggestion online. The online survey gave an insight into the usage of the existing guidelines and the expectations from members; prepublication copy of the revised guidelines were available online for comments and suggestion from the members which were then streamlined and incorporated.
Field and Lohr in 1990 have described Clinical practice guidelines (CPGs) as: "systematically developed statements to assist practitioners and patient decisions about appropriate health care for specific circumstances".  The Institute of Medicine defines clinical practice guidelines as "…statements that include recommendations, intended to optimize patient care, that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options".  CPGs act as a valuable source of information for health care providers in maintaining treatment standards which are up-to-date, evidence based and in accordance with the latest advancements. Guidelines assist the clinicians in the decision making process, help them in taking difficult decisions in complicated cases and allows them to follow a particular treatment course (vs another available one) for the best desired outcome. Guidelines help clinicians defend themselves in the Court of Law. Guidelines describe clinical care based on best available evidence, help maintain consistency in clinical practice, focus on appropriate usage of resources, help in quality control, guide in developing pathways of healthcare which are cost effective and give insight for future research.  Patients suffering from the same problem are likely to receive different care depending on the place, clinician or hospital. Guidelines can simplify this problem by making it more likely that patients receive similar care regardless of the hospital or doctor treating them.  Patients are increasingly becoming aware of treatment options through print and electronic media where they come across lay guidelines; doctors need to inform the patients regarding available treatment alternatives, their potential harms and benefits, where clinical guidelines work as the best available educative tool. CPGs highlight gaps in known literature where treatment recommendations are not clear cut; hence it helps in identifying areas where future research should be focused. Guidelines often act as one of the reference points in audits of clinicians and hospitals for rating them with best care practices.  It is easier for insurance companies to pay for standardized treatment practices; public perception is likely to improve if a health care facility adheres to CPGs and publicizes the same. It is likely that economic advantages of following CPGs is one of the main reasons for their popularity. 
The phrase "evidence- based medicine" refers to the use of treatment that has been tested rigorously to the point of its becoming "state of the art." 7 EBM has received both support and criticism from academicians and clinicians. Evidence based medicine (EBM) contributes to improved quality of CPGs and hence better clinical care given to the patients. Original research and systematic reviews provide the best evidence and have the potential to provide the best health care at the lowest cost. 8 EBMs are best considered as educative tools, which should be used by the clinician for the appropriate group of patients and as check sheets during the process of treatment.  Evidence for a specific treatment, needs to be combined with experience of the clinician and patient's preference for the best possible outcome.
Though it has been found in rigorous evaluations that clinical practice guidelines improve quality of health care, whether they do so in daily practice is less clear. 1 This may be partially because patients, clinicians and managers define quality differently and the current evidence about the effectiveness of a particular guideline may be incomplete. The most important drawback of guidelines is that they may not represent the most appropriate treatment for the individual patient. The members of the expert panel for guidelines development may be mislead by the scientific evidence due to lack of well designed studies; another reason for flawed guidelines may be due to misinterpretation of scientific information.  The expert panel may be biased in favour of a particular treatment due to flawed personal recollections when conflicting data are available for different treatment options.  Due to inadequate time and resources detailed scrutiny of all available evidence may not have been possible. Finally suboptimal treatments may be recommended to control the cost of treatment or balance the interests of doctors and healthcare systems. CPGs may cross the boundary between benefit and harm when clinicians seek for secular (but often self-benefitting) management procedures. Common recommendations often don't take into account the individual medical and psychiatric history of the patient and care at the individual level may not be optimal.  Flawed guidelines compromise quality of care and can misguide the clinicians. Due to time limitations clinicians often find usage of guidelines inconvenient. Algorithms in clinical guidelines which convert patient care into a binary system of yes/no are likely to do grave injustice to the practice of medicine involving complex decision making. A theoretical concern is that of clinicians getting sued for not following guidelines.  Flawed guidelines can also compromise future research and burden health care delivery systems. Hence the editorial team believes that pragmatic use of guidelines which are tailored for the individual, family and the community encompassing nuances of reality and humane treatment are the best options. We are confident these guidelines which are brain child of the best possible expertise in the speciality will go a long way in meeting the expectations of the therapists, clients and the society.
The earlier guidelines were published by the CPG task force but was made available at our IJP Website. The editorial team is grateful for the responsibility bestowed on us to publish to make it available as a supplement of IJP for the easy documentation, dissemination and availability to all, all the time. We are confident that it will serve the purpose of IPS and all the stake holders.
Happy Reading! Long live IPS.
|1||Field MJ, Lohr KN (Eds). Clinical Practice Guidelines: Directions for a New Program, Institute of Medicine, Washington, DC: National Academy Press, 1990.|
|2||Consensus report, Institute of Medicine. Clinical practice guidelines we can trust. March 23, 2011. http://www.iom.edu/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust.aspx |
|3||OPEN CLINICAL: Knowledge Management for medical care: Clinical Practice Guidelines. Available at: http://www.openclinical.org/guidelines.html |
|4||Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. Clinical guidelines: Potential benefits, limitations, and harms of clinical guidelines. BMJ. 1999 Feb 20; 318(7182): 527-530.|
|5||Agency for Health Care Policy and Research. Using clinical practice guidelines to evaluate quality of care. 1. Issues. Rockville, MD: US Department of Health and Human Services, Public Health Services; 1995. (AHCPR publication No 95-0045.)|
|6||Shapiro DW, Lasker RD, Bindman AB, Lee PR. Containing costs while improving quality of care: the role of profiling and practice guidelines. Annu Rev Public Health. 1993;14:219-241.|
|7||Loewy EH.Ethics and Evidence-Based Medicine: Is There a Conflict? MedGenMed. 2007; 9(3): 30.|
|8||Lewis SJ, Orland BI. The importance and impact of evidence-based medicine. J Manag Care Pharm. 2004 Sep;10(5 Suppl A):S3-5.|
|9||Kane RL. Creating practice guidelines: the dangers of over-reliance on expert judgment. J Law Med Ethics. 1995;23:62-64.|
|10||Woolf SH. Shared decision-making: the case for letting patients decide which choice is best. J Fam Pract. 1997;45:205-208.|
|11||Hurwitz B, Eccles M. Legal, political and emotional considerations of clinical practice guidelines. BMJ (in press).|