LAS VEGAS—The newly adopted clinical practice guidelines (CPG) on hoarseness—and concerns that portions are overly simplistic and could harm care—took center stage here in a panel discussion at the Annual Meeting of the American Society of Pediatric Otolaryngology, part of the Combined Otolaryngology Spring Meetings held here April 28-May 2.
Panel members underscored their worries about the guidelines’ direction on laryngoscopy and said that the desire to set evidence-based criteria shouldn’t come at the expense of knowledge gained through years of experience.
The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNS/F) published the guidelines in September (Otolaryngol Head Neck Surg. 2009;140:S4) in keeping with the trend, occurring across medicine, to try to make more treatment evidence-based.
Lucian Sulica, MD, director of voice disorders/laryngology at Weill Cornell Medical College in New York City, said that the published articles on which the guidelines are supposed to be based don’t represent the sum total of what is known about a disorder. “There is really not a substitute for common clinical sense here,” he said. “Information is not the same as knowledge. And the lack of published information is not a lack of knowledge.”
He added that it was “a big problem” that the guidelines did not meet the same peer review standards as the doctors in his audience had to meet for any of their own published papers.
Michael Johns, MD, director of the Emory Voice Center, added, “I think a lot of the troubles that are present in the CPG could have been circumvented by a more patient peer-review process.”
Academy Response
Gavin Setzen, MD, chair of the AAO-HNS Board of Governors, has suggested that such an assessment of the guidelines might be an overreaction. “The otolaryngologist must make a clinical judgment based upon the history and physical findings at the time of initial evaluation,” he said, emphasizing that the guidelines do not “supersede clinical judgment.”
Guideline authors have said that all the comments received about the proposals were considered, even though not all were acted upon.
In a session that association members said was considerably more subdued than the discussions at the Academy when the guidelines were set, David Eibling, MD, chair of the AAO-HNS’ Geriatric Otolaryngology Committee, said he understood the desire for such guidelines.
He shared a chart that showed skyrocketing health care costs in Miami, while in other places, such as Salem, Oregon, they were almost flat. “You have to believe that figures like this make the oversight agencies nuts,” he said, adding that the variation is due to use of discretionary services where evidence is weak. “Hence, the push to establish clinical practical guidelines to standardize care.”
But he said that even in areas where randomized, controlled trials exist, they might not necessarily apply in a particular case. “The patients in studies do not always match the patients sitting in our chair or lying on our operating table,” Dr. Eibling said.
Some things simply cannot be studied, he said, mentioning the joke about how there have been no randomized trials showing that parachutes actually work.
“The bottom line is those who believe that all interventions must be evidence-based need to come down to earth with a bump,” he said. “You are all experts, and your expert opinion matters and, at times, must trump guidelines.”
The guidelines “do not supersede clinical judgement.”
—Gavin Setzen, MD
Concerns
Dr. Johns said the guidelines contain some “great elements,” such as advocating for voice therapy and Botox in the treatment of spasmodic dysphonia, but he reiterated the view that there can’t be much data available for the treatment of hoarseness because it’s a symptom rather than a diagnosis.
A big concern about the guidelines is their weak stance on laryngoscopy. The procedure is given a policy recommendation of “option,” rather than “recommendation” or “strong recommendation.” “I think most of us realize that if someone has chronic voice change, you need to examine the organ that’s involved,” Dr. Johns said. “We need a strong stance on laryngoscopy.”
Another worrisome guideline, Dr. Johns said, was that a three-month allowance or “safety net” of voice change prior to laryngoscopy is advocated, except where symptoms are considered to be “serious.” The problem, he said, is that primary care doctors relying on the guidelines might not know whether symptoms are serious or not.
Dr. Sulica pointed to the literature documenting the risk of delayed diagnosis that might come about if primary care doctors don’t refer patients promptly—and that literature might not pop up in a search of just the term “hoarseness.” “You don’t get this if you pull up ‘hoarseness,’ but you do if you pull up a specific diagnosis like ‘early glottic cancer,’” he said.
The authors of the guidelines have no plans to re-work them. “The hoarseness guideline itself is a very useful tool that will remain an important resource for the broader physician community, and there are no plans for revision,” Dr. Setzen said.
Continued Discussion
Marvin Fried, MD, of the Special Society Advisory Council, which is part of the AAO-HNS Board of Governors, said he hopes such discussions can lead to progress. “We’ve taken the emotion out of it now and we’re now looking at it objectively,” he said. “What the Academy has done is extremely positive—creating guidelines for the future. We’re actively having people participate in this.”
But he added, “The concept is good. The document is not. That is unacceptable.”
Dr. Eibling said that eventually there will be systems to guide treatment but that medicine is not there yet. “I think the emphasis is going to become more on how do we design clinical information systems that assist in decision-making,” he said. “We’re a long ways from it…. Even though memory is flawed, it’s oftentimes, I suggest most of the time, the best we have.”