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Clinical guidelines
  1. G A C MAJOR
  1. Department of Rheumatology, 1st Floor, McCaffrey Wing, The Royal Newcastle Hospital, PO Box 6664J, Newcastle, NSW 2300, Australia

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    Suarez-Almazor and Russell raise several important points in their excellent review about the plethora of clinical guidelines issued by various official, unofficial, learned or merely pretentious bodies.1

    The potential consumer (usually a full time clinician) is advised to evaluate the soundness of the guidelines on the basis of the strength of evidence on which the guidelines are based (that is, double blind randomised trials versus consensus of opinion) and how clearly the supporting evidence is described.

    In reality most guidelines are like an old staircase, with some solidly anchored steps, interspersed with others supported by nothing more than the rickety whim of current opinion. In the end therefore, before deciding that it is safe to climb the stairs, the consumer places his trust more in the pedigree of the authors than in anything else.

    More fundamental than “safety” however is the question of why it was built in the first place. This is very seldom stated, though it is generally assumed to be a worthy reason, which all would share.

    Even worthy reasons can have competing effects however, and unless the primary goal was clearly identified at inception and its priority maintained against the sometimes competing interests of other worthy goals throughout the development of the guidelines, it can be very difficult to discern the distortions that might have been introduced when you only see the final product.

    Guidelines written for the primary purpose of reducing practice variability for cost management, or as a perceived protection against litigation, may also achieve a benefit in reducing morbidity but are likely to be different from guidelines written for the primary purpose of morbidity or mortality reduction, with cost containment the incidental benefit.

    For example, guidelines with the title of “postoperative care after knee replacement” are going to differ in important detail if written for the primary purpose of reducing length of hospital stay, from ones written with the primary aim of maximising functional outcome.

    It should be incumbent on the authors of guidelines to state what their primary purpose was in writing them, which in a manner analogous to a well structured study with an a priori defined primary outcome measure, can then be subjected to assessment.

    In the absence of such a statement, caveat emptor, you may be climbing the wrong staircase.

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