Is it time we adopt clinical practice guidelines?

In human medicine, recognition that the public was not receiving sufficient value for the resources being expended on health care was one of the main drivers for creating clinical practice guidelines (CPGs).

CPGs have been defined by the Institute of Medicine as “systematically developed statements to assist practitioner and patient decisions about appropriate care for specific clinical circumstances.”¹ These guidelines aspire to improve the quality of patient care, decrease health care costs, incorporate relevant research into clinical practice, and reduce the risk of legal liability to practitioners.

CPGs, while not a panacea, have been embraced in human medicine and have, with rare exceptions, consistently been shown to improve clinical outcomes.^2,3 For physicians, CPGs produced by specialist associations, U.S. government agencies, and healthcare organizations have historically been collated by the National Guideline Clearinghouse and the Agency for Healthcare Research and Quality (AHRQ) to assist practitioners and patients in making decisions about appropriate healthcare in specific clinical circumstances.

In veterinary medicine

Although the merits of randomized, placebo-controlled, double-blinded studies, meta-analyses and systematic reviews are well understood, veterinary practitioners should not suffer “analysis paralysis.”

Waiting for higher-quality data to be generated may give one the veneer of the intellectual high ground but does nothing to help the animals that need to be treated now. Veterinarians must work with the current evidence, not the evidence they wish they had. Creating a database of white papers, consensus statements, practice guidelines, position papers, and disease monographs promulgated by veterinary experts and special interest organizations and combining them with a growing body of evidence-based research could serve as an excellent first step for our profession and provide a valuable resource for private practitioners.

These resources would almost certainly provide more relevant and clinically useful information than veterinarians who practice by the unintentional credo of, “Your pet doesn’t have what it has, it has what I know.”

Some of the most commonly reported barriers to why human doctors have not embraced CPGs include lack of awareness/familiarity, disagreement with the published CPG, and inability to overcome the inertia required to try something new.⁴

Other reported concerns directly relate to the quality of the evidence used to create CPGs and the fact CPGs are often created by specialists and experts who may not have experience in general practice care (where the vast majority of patients are treated).

Challenges

While CPGs would be a major step forward for veterinary medicine, some shortcomings, obstacles and challenges associated with CPG generation have been identified in human health care. These include identifying a centralized authority to collect, vet, and catalog guidelines. Although not currently a concern for veterinarians, in human medicine, so many guidelines can be produced for a particular topic clinicians may be forced to sift through what can sometimes be an overwhelming number of them.

Thus, to try and bring some order and consistency to how CPGs are evaluated, a few different instruments for evaluating the methodological rigor and quality of the evidence going in to creating CPGs have been created. These include AGREE (Appraisal for Guidelines for Research Evaluation), an updated version known as AGREE II, and GRADE (Grades of Recommendation Assessment, Development and Evaluation). Both are internationally recognized instruments for evaluating the methodological quality of CPGs. For example, AGREE II includes six specific criteria for evaluating guideline quality including: scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence.⁵

CPGs in veterinary medicine might also assist state veterinary boards in determining whether a veterinarian practiced below the standard of care. If the function of these boards includes safeguarding the welfare of animals and enforcing professional standards, using CPGs, white papers, disease monographs, and consensus statements would create a more objective approach to evaluate individual cases, when a veterinarian’s license is on the line than is the current hodge-podge of medical resources currently used, often including the personal opinions of a board member.

Early steps are being taken toward achieving the goal of a more evidence-based profession in veterinary medicine. For example, with the launch of the Evidence-Based Veterinary Medicine Manifesto, a group of veterinary professionals aims to “drive best practice by helping veterinarians and veterinary nurses access, assess, and use the best evidence to treat and care for animals”⁶ As such, the expected outcome would be to “reduce unnecessary or harmful treatments, better educate clients on the best options for their animals, and inform policymakers on the best approach to advocate for policy changes;” in essence, mirroring many of the stated goals of CPGs.

In human medicine, the incorporation of CPGs into daily clinical practice has sometimes proved challenging.⁷ CPGs cannot become a “straight jacket” for practitioners and must be created with enough flexibility to encompass the wide range of clinical presentations, socioeconomic factors, and diagnostic and therapeutic options.

Given the triadic relationship between veterinarians, their clients, and their patients, combined with the fact animals are still considered property in the eyes of the law, CPGs become even more important, but perhaps even more difficult to create than in human medicine. Even so, as with evidence-based medicine, CPGs are not a substitute for clinical reasoning, rather, they are a valuable adjunct.

Putting into practice

Adopting CPGs should also alleviate some of the anxiety veterinarians experience when they try to determine whether the medical care they propose would potentially fall below the legal standard of care.

In our increasingly litigious society, many veterinarians report their concern about meeting the standard of care results in their practicing defensive medicine, unnecessarily increasing the cost of care.

One study found 35 percent of veterinarians “sometimes” or “often” performed unnecessary tests because they were worried about client complaints, being sued, or becoming subject to disciplinary action.⁸ Removing ambiguity and providing greater consistency for veterinarians looking for practical clinical guidance would undoubtedly be more useful to clinicians than the current opaque standards that individual states use when evaluating cases of potential veterinary malpractice.

In veterinary medicine, CPGs, or similar documents, have already been put forth for a variety of disciplines. Despite their increasing numbers and potential value, these have not been incorporated into veterinary definitions of the standard of care, are rarely—if ever—referenced in state practice acts, and have not been embraced by the American Association of Veterinary State Boards (AAVSB). Only a small fraction has been endorsed by the American Animal Hospital Association (AAHA) and the American Veterinary Medical Association (AVMA).

Nevertheless, they carry weight. For example, the AVMA’s Guideline for the Euthanasia of Animals is widely disseminated and often informs federal and state policy. Thus, there is a role for these resources beyond simply helping clinical practitioners. Although CPGs do not have the force of law in human medicine, they are described as being “situated halfway between ethical rules and legal requirements.”⁹

In human medicine, CPGs are often referenced to help determine whether a doctor breached the standard of care and also to provide an affirmative defense in cases where doctors are accused of malpractice.¹⁰

Conclusion

Until veterinarians embrace and consciously commit to making evidence-based medicine (EBVM) a foundational component of the practice of veterinary medicine, they will continue to be guilty of giving short shrift to the Veterinary Oath, which directs veterinarians to a “lifelong obligation [to] the continual improvement of my professional knowledge.”

More importantly, a failure to commit to EBM fails clients and patients because such failure may present a spectrum of care that is variably divorced from the available evidence and relies on less robust sources of information.

The veterinary profession’s current lack of standardization and ambiguity creates a practical, philosophic, and jurisprudential obstacle to quality veterinary care. However, producing veterinary CPGs make little sense if veterinarians are not going to use them to improve patient care, veterinary state boards are not going to reference them when complaints are made by the public, and the courts are not going to use them to assess whether veterinary practitioners are practicing according to an acceptable standard of care. Synthesizing CPGs for some of the most commonly encountered conditions seen in clinical practice would be a reasonable and achievable initial goal. They would allow veterinarians to get exposed to CPGs in a way that is not overwhelming or intimidating.

Recognizing the benefits associated with CPGs, despite their challenges, should allow veterinary medicine to be able to achieve what David Eddy, MD, PhD, and colleagues noted over 10 years ago when they wrote, “a good set of guidelines should be definitive in nature and be geared toward individualization, incorporating patient preferences, values, treatment risks, and comorbidities to guide clinicians’ choices among an array of possible treatment pathways.”¹¹

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Gary Block DVM, MS, DACVIM, is a board-certified small animal veterinary internist. Along with his wife, Justine Johnson, DVM, he founded and continues to work full-time at Ocean State Veterinary Specialists (OSVS) in Greenwich, R.I., and Bay State Veterinary Emergency and Specialty Services (BSVESS) in Swansea, Mass. Dr. Block has lectured extensively and published numerous articles and book chapters on increasing access to veterinary care, standard of care, animal welfare and veterinary ethics. Block is the current president of the Evidence Based Veterinary Medicine Association (EBVMA), with different members writing this column. While all articles are reviewed for content, the opinions and conclusions of the author do not necessarily reflect the views of the EBVMA or Veterinary Practice News. For information about the association or to join, visit EBVMA website.

References

1. Field MJ, Lohr KN. Institute of Medicine. Committee on Clinical Practice Guidelines. Division of Health Care Services. Guidelines For Clinical Practice: From Development to Use. Washington: National Academy Press; 1992.
2. Bahtsevani C, Uden G, Willman A. Outcomes of evidence-based clinical practice guidelines: a systematic review. Technol Assess Health Care 2004;20(4):427–33.
3. Murad HM. Clinical Practice Guidelines: A Primer on Development and Dissemination. Mayo Clin Proc 2017;92(3):423–33.
4. Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999;282(15):1458–65.
5. AGREE Next Steps Consortium (2017). The AGREE II Instrument. Retrieved Dec. 1, 2023, from http://www.agreetrust.org.
6. Launching an evidence-based veterinary medicine manifesto to drive better practice. Vet Rec 2020;187(5):174–7.
7. Guerra-Farfan E, Garcia-Snachez Y, Jornet-Gilbert M, et al. Clinical practice guidelines: The good, the bad, and the ugly. Injury 2022 S0020-1383(22)00077-00078.
8. Bryce AR, Rossi TA, Tansey C, et al. Effects of client complaints on small animal veterinary internists. J Small Anim Pract 2019;60(3):167–72.
9. Pugliese M, Voslarova E, Biondi V, et al. Clinical Practice Guidelines: An Opinion of the Legal Implication to Veterinary Medicine. Animals 2019;9(8):577.
10. Mackey TK, Liang BA. The Role of Practice Guidelines in Medical Malpractice Litigation. AMA Journal of Ethics 2011;12(1):36–41.
11. Eddy D, Adler J, Patterson B, et al. Individualized Guidelines: The Potential for Increasing Quality and Reducing Costs. Annals of Int Med May 3, 2011.
12. Some of the material in this article first appeared as part of a book chapter by the author in Advances in Small Animal Care 2023, Volume 4(1).