LYMEPOLICYWONK: IDSA Lyme Hearing Panel–What to do when opinion is strong, but evidence is weak?
Now that two studies have shown that IDSA guidelines are generally long on opinion and short on evidence, what should the IDSA guideline panel do? The study by Lee, discussed in yesterday's blog, found that IDSA frequently makes strong recommendations, but that these strong recommendations are supported by strong evidence only 15% of the time. Dr. Maloney found that the majority of recommendations in the IDSA Lyme guidelines were based on the weakest level of evidence–expert opinion. Shouldn't clinical judgment only be suppressed when there is strong evidence? That's what the American Academy of Pediatrics says in its guidelines on making guidelines.
In these circumstances, the treating physician has more information than the centralized guidelines committee. Only the treating physician has examined the patient, knows the severity of the illness, the history of the illness, the course of illness and the patients responsiveness to medications. Guidelines should only override this information when the evidence is certain–not when it is weak or when more research needs to be done. The American Academy of Pediatrics agrees with this assessment. Below is their chart, which indicates that in the absence of strong evidence, guidelines should provide for treatment options and leave the decision to the treating physician.
Bottom line, when the guidelines are relying on expert opinion, they should defer to clinical judgment or provide no recommendation. Even when there is strong evidence, the guidelines recommend providing treatment options if the balance of the benefit and harm so dictate. Here, we have seriously ill patients who without treatment options are provided with no care. Treatment could restore their health and, according to the CALDA survey of 3,600 patients, most improve with treatment.
You can find the AAP article here: Classifying Recommendations for Clinical Guidelines.