Making guidelines an ally

How avidly do clinicians follow guidelines? Perhaps only to the degree that their worth is apparent and appreciated.

Guidelines came to the forefront this week, either with the release of new recommendations or the use of old ones. In one case, researchers showed that applying guidelines can save a hospital millions of dollars annually, simply by integrating guideline parameters in an electronic ordering system.

A team from Christiana Care Health System in Newark, Delaware, applied telemetry use and duration recommendations from the American Heart Association (AHA) into their electronic ordering system in an effort to improve appropriate use of the technology. In a before-and-after analysis they demonstrated that the change reduced the daily number of patients monitored and duration without an increase in code blue mortality, hospital census or rapid response activations.

The reductions saved the hospital system more than $13,000 per day, which added up to an estimated $4.8 million annually.

On another front, the National Lipid Association (NLA) unveiled recommendations to help clinicians manage patients who are at risk of cardiovascular atherosclerotic disease. Co-author and NLA President Terry A. Jacobson, MD, emphasized in an interview with Cardiovascular Business that the recommendations were not meant to supplant the controversial 2013 guidelines from the AHA and the American College of Cardiology (ACC).

He called parts of the AHA/ACC document “excellent,” but like many others in the medical community, the NLA differed on the elimination of targets for low-density lipoprotein (LDL) cholesterol.

The NLA also underlined the importance of monitoring non-high-density lipoprotein (non-HDL) cholesterol, which mounting evidence shows to be a better marker than LDL cholesterol. Non-HDL is total cholesterol minus HDL cholesterol. Shifting the focus of patients and some physicians to non-HDL is a challenge, but raising awareness will help.

The AHA and ACC also revised guidelines to help cardiologists manage patients with non-ST-elevation acute coronary syndromes. The update recognizes the difficulty in distinguishing between unstable angina and NSTEMI and brings them together in a revision of the 2007 document.

In the case of the ABIM Foundation Choosing Wisely list, the ACC applied an update by using the delete key. The list originally contained five practices that physicians and patients should question, but recently it has spared one that challenged the necessity of coronary interventions that extend beyond revascularization of a culprit lesion.

Now, whether clinicians fold these recommendations into practice is another matter. In the case of cholesterol guidelines, Jacobson suggested a hybrid approach, choosing those recommendations that work best. The NLA sees LDL targets as a useful tool for motivating patients and for monitoring adherence.

Jacobson added that we don’t need more guidelines but that we do need more discussion on the issues. Would you agree?

Candace Stuart

Editor, Cardiovascular Business