Creating Treatment Guidelines

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In 2006, a panel formed by the National Committee for Quality Assurance, an organization that sets treatment guidelines often used by insurance companies to determine their reimbursement policies, unanimously recommended that doctors pursue intensive blood glucose control in nearly all people with diabetes. But in early 2008, the group withdrew its guideline after the intensive-control arm of the ACCORD (Action to Control Cardiovascular Risk in Diabetes) Study was halted due to a significantly higher death rate in that group of participants. The earlier studies that the group had considered, it seems, did not include enough people with cardiovascular disease.

According to a New York Times article published last week, this episode shows some of the general hazards posed by treatment guidelines, as well as some possible flaws in the system used to create them. The original guidelines produced by the National Committee for Quality Assurance seem to have failed to take into account a significant subset of people with Type 2 diabetes, those with cardiovascular disease. But no treatment guidelines can carve out exceptions for every situation in which standard treatment may not be the best. Thus, they should ideally strike a balance between educating doctors and allowing doctor discretion. It is important to remember, however, that the guidelines in question are not simply clinical practice recommendations such as those issued by the American Diabetes Association. Instead, they are used to determine, in some cases, how doctors are paid by insurance companies for treating people.

What do you think — what is the appropriate balance between allowing the discretion of doctors and enforcing the accepted best practices for treatment? Should payment from insurance companies be tied to how closely doctors adhere to treatment guidelines? And given that there is conflicting evidence regarding tight blood glucose control and risk of death, how should treatment guidelines account for such a situation? Was the National Committee for Quality Assurance too quick to jump on one study and ignore the benefits of tight blood glucose control? Leave a comment below!


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