Skip to content

Why Do Medical Guidelines Vary So Much?

Are you aware that other countries do not recommend all the tests and screenings that medical specialty organizations in the U.S. recommend? Medical panels in different parts of the world may issue guidelines that vary from U.S. medical specialty guidelines, and sometimes even conflict with them. This is happening even though all groups in various countries are looking at the same medical evidence on which to base recommendations.

This is because in the United States (unlike European countries and Canada) there is a fee for service medical system - the more tests, screenings, and procedures, the more a doctor is paid. Conflict of interest? Bias? Of course. Does it make for better care for patients? Based on the evidence - no.

Interestingly, independent medical groups in the U.S. (such as the U.S. Preventive Services Task Force) that don't have financial interests in the medical services at stake recommend guidelines that are more in line with Canadian and European country guidelines. The U.S. Preventive Services Task Force is an "independent, volunteer panel of national experts in disease prevention and evidence-based medicine".

As many have pointed out, the approach recommended by medical specialty groups of more and more tests and screening leads to  overdiagnosis, overtreatment, and increasing health care costs. There also is specialty bias - which means whatever the physician is trained in, they are biased toward recommending those treatments and procedures. [Similarly, Dr. John Mandrola has written about the issue of employers evaluating physicians on the number of tests and procedures done (with the more, the better the evaluation), and on the harms that can result from screening, tests, and procedures.]

Dr. Ismail Jatoi (Univ. of Texas Health) and Dr. Sunita Sah (at Cornell) have written a thought provoking article in the Canadian Medical Association Journal about these issues with a call to reduce these conflicts when medical organizations give medical guidelines. The panels should be multidisciplinary in composition, independent of specialty societies, and avoid fee-for-service conflicts of interest.

From Science Daily: Medical guidelines may be biased, overly aggressive in US

Dr. Sunita Sah practiced general medicine for several years in the United Kingdom's National Health Service. When she came to the United States, she noticed something strange. The U.K. guidelines for tests such as mammograms and colon cancer screenings drastically differed from those in the U.S. -- even though they were based on the same medical evidence.

"Having colonoscopy at the age of 50 -- that struck me as rather odd when I moved to the U.S., because you don't really hear about people having colonoscopies as a screening procedure in the U.K.," said Sah. "It's much less invasive to test for blood in the stool. It's also less costly and doesn't have the risks of undertaking a colonoscopy."

Now an assistant professor of management and organizations at Cornell, Sah and Ismail Jatoi of the University of Texas Health, San Antonio, say the treatment guidelines recommended by medical specialist organizations are more likely to call for greater use of health care services and exacerbate overdiagnosis, overtreatment and spiraling health care costs. Their commentary, "Clinical Practice Guidelines and the Overuse of Health Care Services: Need for Reform," appeared March 18 in the Canadian Medical Association Journal.

The implications are significant, she said, because guidelines are supposed to provide standard evidence-based treatment practices for all doctors.

"The recommendations put out by specialty organizations -- like the American College of Cardiology or the American College of Radiology -- show specialty bias in recommending more aggressive and/or more frequent screening procedures," said Sah, an expert on conflict of interest. "In the U.S. in particular, where the fee-for-service compensation model dominates medicine, which is different from countries like the U.K., you see even more recommendations for greater use of health care services."

Specialty bias refers to the tendency of physicians to recommend the treatments in which they are trained to deliver. For example, localized prostate cancer can be treated with either surgery or radiation.

"If you go to a surgeon, chances are that they are more likely to recommend that you have surgery; if you go to a radiation oncologist, they are more likely to recommend that you have radiation," she said. "They each often believe that the treatment that they're trained in is the better one."

In the case of screening for colorectal cancer, the American College of Gastroenterology's panel -- all of whom were gastroenterologists -- recommended colonoscopy as the best strategy.

But the United States Preventive Task Force, with no gastroenterologists or gastrointestinal surgeons, recommended testing the stool, and sigmoidoscopy (an exam of only the lower part of the colon) or colonoscopy as a last resort. Stool testing was also recommended by the European Society of Medical Oncology panel, which consisted of six medical oncologists, no gastroenterologists and one gastrointestinal surgeon. The panel said there was limited evidence that screening colonoscopy is effective.

Specialty guidelines are also subject to fee-for-service bias, according to the commentary. Doctors who receive a payment for each treatment may tend to recommend that treatment more often, because they have a financial interest in it. "The bias is not necessarily malicious or intentional," Sah said. "In a fee-for-service environment, they may be biased to do more rather than less, so it becomes a habit." But more is not necessarily better, she said. "Sometimes the risks of those procedures are just not worth the benefits."

The authors call for a reduction in conflicts of interest in the fee-for-service model, and more professional diversity in the makeup of the guideline committees. "You need a variety of different voices on those committees," Sah said.

Leave a Reply

Your email address will not be published.