Why Clinical Guidelines Are Important and How They Come Together

The 2014 release of the tinnitus clinical practice guideline by the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) changed the way Minka Schofield, MD, treated patients with tinnitus.

“Before this guideline, vitamins, steroids, and melatonin were all being used in an effort to help patients with tinnitus. We’d actually done our own study that showed maybe 50% of the people who take melatonin do get better, so we were recommending melatonin as an option. Then the guideline came out and stated there’s no significant evidence for any of these interventions,” said Dr. Schofield, an otolaryngologist at The Ohio State University Wexner Medical Center. “I stopped giving melatonin once the guideline came out.”

Clinical practice guidelines are intended to influence practice. They synthesize the best available scientific evidence, making it easier for clinicians to stay up to date on the latest evidence-based practices. But some clinicians think that clinical guidelines are overly prescriptive and overlook the art of medicine.

“Some people view guidelines as threats to their autonomy and to proper patient care,” said Richard Rosenfeld, MD, MPH, Senior Advisor for Guidelines and Measures at AAO-HNS. “Many feel their experience as a clinician and their judgement are often all that’s needed, and in some cases, that may be true.”

Increasingly, though, the public (and payers) are demanding quality, evidence-based care. “If you look across the country, there are large variations in the frequency of certain procedures and treatments; it’s all over the map. Some of it is likely justified, but a lot of it probably is not,” Dr. Rosenfeld said. Clinical guidelines, he said, are an opportunity to reduce unjustified variations by identifying knowledge gaps, defining best practices, and promoting quality improvement opportunities.

[The AAO–HNS] realized we needed to start developing trustworthy guidelines that would give us credibility on the national stage, thereby allowing us to advocate properly for the interests of otolaryngologists. —Richard Rosenfeld, MD, MPH

A History of Clinical Guidelines in Otolaryngology

The development of clinical guidelines in medicine began in the 1990s, concurrent with the push toward evidence-based medicine. The National Guideline Clearinghouse, a publicly available database of clinical practice guidelines, was formed in 1998 under the Agency for Healthcare Research and Quality in the U.S. Department of Health and Human Services. But the AAO-HNS didn’t begin producing clinical guidelines until the 2000s.

The clinical indicators and procedures released by AAO-HNS in the early 2000s lacked rigor and were not considered trustworthy by the American Medical Association and the Centers for Medicare and Medicaid Services (CMS), Dr. Rosenfeld said. “We realized we needed to start developing trustworthy guidelines that would give us credibility on the national stage, thereby allowing us to advocate properly for the interests of otolaryngologists,” he said. So AAO-HNS formed the Guidelines Development Task Force in 2005, with Dr. Rosenfeld as chair.