Reducing Practice Variation
The recommendations also help to reduce variation in practice across the military services and the VA network. In addition, they “serve to reduce errors, and provide consistent quality of care and utilization of resources throughout and between the VA and DoD health care systems. Guidelines are also cornerstones for accountability and facilitate learning and the conduct of research,” according to the VA website.
The teams are multidisciplinary, with everyone who has a hand in caring for patients with the condition coming together to evaluate the evidence and make recommendations. For the recently completed guideline on lower back pain, Sall noted, the team included orthopedists, nurses, chiropractors, case managers, physiatrists, pain specialists, behavioral health specialists and others.
“We’re one of the only organizations that has been able to get patient input into guidelines, as well,” he noted. “We develop key questions we want the guidelines to answer, then assemble veterans and patients who receive care through the military healthcare system and ask what changes they would like to see addressed. Sometimes their concerns are central to formatting the update and recommending that clinicians take into account patient values and input.”
The Work Group currently has 24 completed guidelines and it updates four or five each year. The group is developing a new guideline this year on sleep disorders because “lack of sleep has huge impact on several diseases we have guidelines for, including diabetes and hypertension,” Sall said. FY2018 will also see updates to the stroke, asthma, suicide prevention and chronic kidney disease guidelines.
The Work Group generally reviews guidelines every five years, but there are exceptions. A new “black box” warning or approval of significant new medications may prompt a partial update earlier. Clinicians might also ask the group to consider updating guidelines sooner than usual, if practice has changed or evidence shows better options than the current recommendations. That happened this year when a member of the VA’s nephrology community encouraged an evaluation of the chronic kidney disease guidelines, Sall noted.
Occasionally, a guideline may remain unchanged for longer periods. The Work Group previously considered updating the bipolar disease guideline, which is now seven years old, but clinical leaders who see patients with the condition indicated that treatment had not changed enough to warrant a full revision, according to Sall.
The guidelines reflect the ongoing communication with clinicians that goes into the development and update process. “Clinicians don’t want a cookbook for medicine. These are evidence-based clinical practice guidelines, not clinical pathways that instruct physicians to follow certain steps,” Sall said. “Pathways can take some physician decision-making out of the treatment process and often ignore patient desires.”
The VA website clearly expresses that perspective, saying that “the use of guidelines must always be in the context of a health care provider’s clinical judgment in the care of a particular patient. For this reason, the guidelines may be viewed as an educational tool to provide information in shared decision-making.”
The educational and time-saving aspects of the guidelines should not be underestimated. “They really help clinicians synthesize and integrate the latest evidence into their clinical practice,” Sall said. “There is so much evidence coming out all the time, I’ve seen estimates that the average primary care physician would have to read 17 articles a day to just stay current. With evidence-based guidelines, they can just read through and see what the current evidence recommends.”
Research on fibromyalgia, a poorly understood, chronically disabling pain syndrome, generally has focused on its clinical presentation and treatment.
The VA is expanding remote management of patients to improve disease prevention and care.