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The waiting game

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)

  • Do Guideline committee members declare their interests? How many are in the pay of pharmaceutical companies or represent organisations sponsored by big pharma?

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  • Great. So we are held to account when we don't follow guidelines. And now criticised when we do follow guidelines.

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  • And how much consideration for inadequate resourcing is in the guidelines. NICE say it's a factor but it's not clear to me how much that stops the iniquity of 'excellence creep'.

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  • Agree with all posting.
    It could be a lot clearer where the conflicts of interest of these so called medical experts lie.
    There will no doubt be someone posting in aminute about how the wonders of the free market can sort this all out....

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  • You don't need the free market to sort this out. The government just needs to get out of the way and allow medical colleges and free thinking scientific authors to come up with any guidelines as they see fit and to have their publications scrutinised rigorously by the scientific community in peer reviewed publications. The government has no business coming up with "national guidelines" for anything and only does so in order to satisfy its own self interests.

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  • Angus,
    to whom could you be referring??

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  • How many cars will we need to get there?
    Two, said three experts
    Three, said three more.
    NHS solution - buy three cars, cut one in half, throw half of it away and give the results to primary care. Repeat and repeat.
    Copyright Institute of Ivory Medicine.

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  • NICE should have been shut down years ago, it consumes vast amounts of tax-payers cash that would be better spent on front-line healthcare provision. It's guidance is often of poor quality or simply difficult to apply to the real world NHS under strain. It creates a world of painful legal problems for doctors and does little to protect anyone from harm, driving the demand for investigation and treatment. NICE was designed for the pre-internet era when information was harder tom come by. Why on earth have we allowed this to continue?

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  • Ahh Angus, my ears were burning :)
    I have never said the free market is the solution to ALL problems, it is simply the best and most efficient system to have :) Its where the consumer/customer/patient/frontline worker
    has the most impact on demand/quality/practicality/affordability.

    Corruption is always a stumbling block both in the free market and with the state. The solution to that is transparency/free speech to criticise. A state working truly for its citizens would want to maximise that, not restrict it.

    The answer to your question above, Man Friday, is that power corrupts, and states don't cede power back to the public easily.

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  • Dear All,
    Perhaps it might help by correcting the articles fundamental error, in calling any of these people who sit in these ivory palaces as being "experts". They are more properly described as "people with opinions". So we should take due account guidelines drawn up by a group of people who have opinions. Excellent.
    That makes the way forward much easier. Also remember what Professor Sir Michael Rawlins, then Chairman of NICE, said about NICE guidelines.
    Paul C

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