While Imperfect, Anesthesia Guidelines Help Busy Clinicians

Karen B. Domino, MD, MPH

Professor of Anesthesiology & Pain Medicine
University of Washington, Seattle

Martin J. London, MD

Professor of Clinical Anesthesia
University of California, San Francisco

Avery Tung, MD

Professor of Anesthesiology & Critical Care
University of Chicago

In the March issue of Anesthesiology News, Robert E. Johnstone, MD, criticized anesthesia practice guidelines, citing “practice guidelines are out of control—too many to adopt, too anecdotal to accept, and too political to take seriously.”¹While Dr. Johnstone makes some important points, especially regarding the vast proliferation of guidelines by many medical societies using inadequate scientific methodology, we strongly believe that the benefits of carefully performed and scientifically valid practice guidelines vastly outweigh their limitations.

The American Society of Anesthesiologists (ASA) began creating practice parameters in 1992 and has produced 22 practice parameters and 25 updates in the past 25 years. Unlike many other guideline-creating organizations, the ASA uses a broad-based, multidimensional approach to practice parameter development, including review and evaluation of all available published scientific evidence, meta-analysis of randomized controlled trials, expert and practitioner opinion based upon formally developed surveys, and feedback from practitioners.^2,3

The ASA was one of the early adopters of a formal “evidence-based linkage” strategy to formulate guideline questions. The importance of precisely formulating guideline questions that are ultimately most useful to practicing clinicians has only recently been formally codified by other influential clinical societies, such as the American Heart Association and the American College of Cardiology. Members of each ASA task force are screened for potential conflicts of interest and represent a variety of anesthesiologists, occasionally other specialists, and two PhD methodologists to ensure adherence to scientific methodology.^2,3

The ASA practice parameters are divided into guidelines (which include meta-analytic findings from randomized controlled trials) and advisories, in which the same evidentiary collection process is used, but there are fewer scientific studies and insufficient quantities of data appropriate for meta-analysis. The transparency of specific types of evidence that are used makes it easier for the practitioner to understand the contribution of existing literature and expert and practitioner opinion for each recommendation.

We note that not all societies provide this level of scientific review, practitioner scrutiny and transparency. The 2016 Surviving Sepsis Campaign guidelines, for example, generates 71 recommendations, of which 13 are classified as “strong recommendation, weak evidence” and 21 as “weak recommendation, weak evidence.”⁴ Although such recommendations may be valid, no information is provided to help readers understand how similar grades of evidence led to disparate recommendation strengths. In addition, nearly all of the evidence for the universally adopted protocols of Basic and Advanced Cardiac Life Support (based on AHA Guidelines) is poor, but this is all that is available.⁵

So why has the ASA invested so much time and money in developing practice parameters? Many reasons exist, but first among them is that practice parameters have significantly contributed to clinical practice. They condense an often vast scientific literature into a single document with a focus on real-world clinical decision making. For those interested in how the evidence is analyzed, each document provides a thorough explanation and includes a detailed list of scientific evidence. For busy practitioners, all of the recommendations are summarized on an easy-to-read page.

Among their other benefits, practice parameters thus provide an easy way for clinicians to keep up-to-date! Decreases in malpractice rates after publication of the original ASA standards for basic monitoring⁶ and improved patient outcomes after adoption of the difficult airway algorithm are examples of such benefits.⁷

Because of these attributes, practice parameters produced by the ASA are extremely popular with clinicians. In the last ASA membership survey (2015), standards and guidelines ranked highest among the benefits of ASA membership in importance to practice (4.43), with 89% reporting usage (n=4,379). Fully 61% had accessed the practice parameters in the prior year. Survey participants ranked the ASA Practice Standards and Guidelines among the top five benefits members receive. From June to August 2012, among nearly 1 million page views on the ASA website, standards and guidelines were second only to the ASA home page/Annual Meeting site. From 2008 to 2012, 15 of the most-viewed papers in Anesthesiology were ASA practice parameters² and the top two cited articles in Anesthesiology from 2000 to 2012 were practice parameters.^8,9

Dr. Johnstone suggested that guidelines may be most useful for plaintiff lawyers.¹ However, guidelines are probably most helpful in the defense of guideline-compliant clinical care as they provide an explicitly derived, scientifically rigorous analysis of existing knowledge rather than just one more expert opinion. As Dr. Johnstone noted, Tom Price, MD, secretary of the Department of Health and Human Services, has recommended use of clinical practice guidelines in defense against malpractice claims.¹⁰

The Anesthesia Closed Claims Project, funded by the Anesthesia Quality Institute, has seen many claims for ulnar neuropathy and postoperative visual loss successfully defended using the ASA Practice Advisories.^11,12 Poor outcomes after an unexpected difficult intubation have also been successfully defended if the difficult airway guideline was followed.⁷ Scientifically rigorous practice guidelines from major societies such as the ASA are the anesthesiologist’s friend in court, not their enemy.

Scientifically valid and transparently produced practice parameters also have many benefits for patients. In addition to keeping practitioners up-to-date, they can limit unnecessary variation in care, foster consistent decision behavior, reduce patient harm and facilitate research by clarifying existing gaps in knowledge. Problems with past systematic reviews have propelled reevaluation of scientific validity of systematic review and meta-analyses.^13-15 Only medical societies with sufficient methodological expertise can implement these improvements, and we agree with Dr. Johnstone that “cutting the bad ones will elevate the good ones.”¹

Good guidelines really do help busy practitioners take better care of their patients!

References

1. Johnstone RE. Glut of anesthesia guidelines: a disservice, except for lawyers. Commentary. Anesthesiology News. March 3, 2017. http://www.anesthesiologynews.com/?Commentary/?Article/?03-17/?Glut-of-Anesthesia-Guidelines-a-Disservice-Except-for-Lawyers/?40561?ses=ogstAccessed April 11, 2017.
2. Apfelbaum JL, et al. The genesis, development, and future of the ASA evidence-based practice parameters. Anesthesiology. 2013;118:767-768.
3. Connis RT, et al. Evaluation and classification of evidence for the ASA clinical practice guidelines. In: Miller’s Anesthesia.5th ed. Miller RD, ed. Philadelphia, PA: 2015;3257-3270.
4. Rhodes A, et al. Surviving Sepsis Campaign: International guidelines for management of sepsis and septic shock: 2016. Intensive Care Med. 2017;43:304-377.
5. Jacobs AK, et al. ACCF/AGA clinical practice guideline methodology summit report: A report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. 2013;127:268-310.
6. Posner KL. Data reveal trends in anesthesia malpractice payments. ASA Newsletter. 2004;68:7-8, 14.
7. Peterson GN, et al. Management of the difficult airway: A closed claims analysis. 2005:103:33-39.
8. Gross JB, et al. Practice guidelines for sedation and analgesia by non-anesthesiologists: An updated report. Anesthesiology. 2002;96:1004-1017.
9. Caplan RA, et al. Practice guidelines for management of the difficult airway: An updated report. Anesthesiology. 2013;118:251-270.
10. Terhune C. Top Republicans say there’s a medical malpractice crisis. Experts say there isn’t. Kaiser Health News. January 4, 2017. http://khn.org/?news/?leading-republicans-see-a-costly-malpractice-crisis-experts-dont/?. Accessed March 11, 2017.
11. Apfelbaum JL, et al. Practice advisory for the prevention of perioperative peripheral neuropathies: An updated report. Anesthesiology. 2011;114:741-754.
12. Apfelbaum JL, et al. Practice advisory for perioperative visual loss associated with spine surgery: An updated report. 2012;116:274-285.
13. Ioannidis JPA. The mass production of redundant, misleading, and conflicted systematic reviews and meta-analyses. The Milbank Quarterly. 2016;94:485-514.
14. Lakens D, et al. On the reproducibility of meta-analyses: six practical recommendations. BMC Psychology.2016;4:24-33.
15. Moller AM, Myles PS. What makes a good systematic review and meta-analysis? Br J Anaesth. 2016;117:428-430.