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GPs go forth

Major GP guidelines mostly ‘based on expert opinion and not evidence’

A review of major UK guidelines for monitoring chronic diseases in primary care has found most are based on expert opinion and that even when evidence is cited it is not clear whether recommended tests within the guidelines are necessary.

The review, published in the BMJ and conducted by researchers at the University of Bristol, looked at guidelines for monitoring type 2 diabetes, hypertension and chronic kidney disease, produced by organisations including NICE, the Scottish Intercollegiate Guidelines Network and the RCGP, and found the advice varied widely.

Recommendations about how frequently tests should be carried out are 'entirely' based on expert opinion, according to the researchers, from the Government-funded National Institute for Health Research.

When reviewing each guideline, the authors found no recommendations for monitoring were based purely on evidence - and all included the expert opinions of the guideline development group members.

They found that where evidence was referred to, it often did not address the questions of whether the test was beneficial and necessary for monitoring.

Advice on the frequency of testing varied between all the guidelines, for example with SIGN recommending annual testing of renal function in patients with type 2 diabetes and NICE recommending that testing intervals should depend on the patient’s previous renal function results.

The authors highlighted 'there is no evidence to support frequency of testing of any test in any of the guidelines' and that 'recommendations regarding frequency of testing are entirely based on expert opinion'.

GPs may, as a result of these uncertainties, be carrying out unnecessary additional testing, warned the researchers.

The paper said: 'Unnecessary testing in a low prevalence setting such as primary care is more likely to lead to false positives, which in turn can lead to cascades of follow-up testing. This can generate anxiety for patients, increased workload for doctors, and increased costs for the health service. False negative results, on the other hand, may lead to false reassurances and delayed diagnosis.’

The review calls for more rigorous research methods to develop evidence-based recommendations on monitoring chronic disease.

The researchers said: 'Robust evidence for optimal monitoring strategies and testing intervals is lacking. Most of these recommendations are based on expert opinion, provided by the respective guideline development groups. None of the recommendations are solely based on evidence.'

They concluded: ‘We recommend using the current guidelines where clear testing recommendations are given, as they are based on the best available evidence. These guideline recommendations should feed into, rather than override, discussions with patients that incorporate their values and preferences.

They added: ‘In the absence of clear evidence… GPs should ensure that there is a clear clinical rationale for each test that they perform. As chronic disease monitoring is often delegated to nursing staff or healthcare assistants, GPs should consider offering training about these uncertainties and the potential harms of over-testing to the wider primary care team.’

NICE announced plans earlier this year to lower the threshold for considering hypertension medication in patients at risk of cardiovascular disease, leading to a warning from the BMA that this would increase workload and pressures on GPs.


Readers' comments (20)

  • ‘I told you so’ said X
    ‘Bollicks’ said Y
    ‘Let’s just meet in the middle’ said X
    ‘Just FO’ said Y
    And they all lived happily ever after!

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  • Vinci Ho

    How many times have we fallen into these ‘traps’ set up inadvertently (arguably so) by these academics up the top floor of the Ivory Tower. The problem is there is also a twin tower called Big Brother Tower . If you do not follow the guidelines and ‘accidents’ happen, you are f***ed( expletive) standing in court .

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  • How ironic. A government funded scientific study finds that uk government medical guidelines are not evidence based. Not surprising. NICE “panels” that come up with these guidelines are made up of a concoction of people, which may include GPs, drug company representatives and “lay people” lol some of the doctors themselves may have nothing to do with the particular branch of medicine they are supposedly coming up guidelines for. They’re mostly for domestic consumption these “guidelines” and are not quotes or referenced by any international peer reviewed publications into the relevent fields.

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  • Agree with above comments.

    There is also no analysis of how much extra time / resources are required to deliver the latest guidelines, which never reduce the workload for GPs.

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  • please-delete-this-fucking-profile-i-cant-delete-it-in-my-account-settings

    the evidence is lacking but the consequences are vast

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  • Rogue1

    Well there is a surprise!
    And why should we believe the opinion of a Dr stuck in an ivory tower over the opinion of Dr that actually see patients?
    Yet I fear they are here to stay and beat us with

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  • There should be a criteria that the "expert" is currently practicing FULL time and not just one or 2 sessions so he/she feels the full force of their recommendations in action and see it work or not work.
    Clinicians can then have confidence in this as their clinical experience is at least equivalent.
    A 2 session doctor can virtually never be as expert as an 8 session doctor. Experience counts.

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  • Not saying that I agree with all the guidelines, but why is secondary care not financially remunerated according to guidelines, like primary care?

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  • David Banner

    Nitwits Ignoring Clinical Evidence.

    These are the clowns who tried to impose FeNO testing and comically ignorant diabetes guidelines on us recently.
    But whilst we all laugh at and ignore their “cost effective” demented nonsense, the truth is that these deeply flawed dictats may be used as evidence against you by your local friendly GMC one day.
    Depressing and terrifying in equal measures.

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  • Having secondary care experts dictate guidelines to GP's is like the chef of a fine dining restaurant dictating how to run an all you can eat buffet

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