Lines & Latitude

Lines are straight and narrow. Tacking “guide” before them in the medical world, where the best course of action may not be straightforward and contributing factors can be wide, may create confusion.

Take, for example, the American Heart Association/American College of Cardiology guidelines for reducing the risk of atherosclerotic cardiovascular disease. In this issue, we explore two contentious elements in the 2013 guidelines: dropping the use of low-density lipoprotein targets and the introduction of a new risk estimator.

The guideline writers designated a risk score of 7.5 percent or higher as a trigger for considering statin therapy for a patient. It is not a dictate, but rather a signal for a cardiologist or primary care physician to discuss risk factors and options with the patient. The recommendations address the need to incorporate a patient’s values and preferences into any decision to initiate statin therapy.

This patient-centered approach isn’t new and isn’t limited to cardiology guidelines. It is an oft-repeated message but it may seem hollow to physicians. Some decisions are cut and dry: The evidence clearly shows this action offers a huge benefit at little or no risk, or no to little benefit at immense risk. Those situations should be obvious and reasonably easy to convey to a patient. But what about cases that are more ambiguous and complicated?

Clinical judgment also is an oft-repeated term. A physician evaluates the greater context of an individual patient and uses his or her clinical expertise and insight to reach a decision. Sometimes the decision, while appropriate under specific circumstances, is not “in line” with recommendations.

This is a little squishy, but it goes hand-in-hand with patient-centered care. Like shifting the emphasis to the patient, the message in guidelines may need to be reoriented to explicitly, and if necessary repeatedly, let physicians know that straddling the lines is an option.
The message is there, but it may be time for front billing.