Are Your Patients Better Off Today?

From the American Society of Nephrology annual meeting in Philadelphia

The challenges of complex clinical care in the age of evidence-based medicine have been prominent at the annual meeting of the American Society of Nephrology here.

Nephrologists today are facing increasing difficulties, as pressure builds upon them to develop and adhere to evidence-based guidelines for expensive procedures such as dialysis, despite the fact that there have been few randomized controlled trials in their specialty.

In a debate yesterday, some authorities questioned whether the efforts that began more than a decade ago to develop and implement guidelines had been helpful. “Are your patients better off today than they were in 1996?” was the question. The answer wasn’t entirely clear.

One point of view was that some studies have suggested that the guidelines and clinical practice recommendations developed thus far have been helpful and that structured systems and the establishment of specific therapeutic targets has been associated with improved outcomes. But other experts argue that disparities in care remain unmet.

“Our guideline process has gotten lost and needs adjustment to get back on track,” said Dr. David C. Mendelssohn of the University of Toronto. “Clinical practice guidelines have morphed into something we did not expect, with results that have not been helpful, including the denial of care,” he said.

This morning another session focused on new recommendations that are under development for chronic kidney disease-associated metabolic bone disease. With an overflow crowd in attendance (I was crammed in among the overflow, sitting on the floor up front), experts described the difficulties they continued to face in this difficult aspect of care for patients with chronic kidney disease. In fact, they acknowledged that their upcoming recommendations—which have been delayed and now are expected to be published early in 2009, once they finish addressing the numerous comments that arose during the review process—actually will be less specific than were the previous recommendations.

For example, there no longer will be specific target values for patients on dialysis for serum phosphate or parathyroid hormone levels. Rather, the new guidelines will be more guarded, stating that extreme ranges of risk should be avoided.

Tomorrow morning, there’s yet another session entitled “Clinical Practice Guidelines: Consensus and Controversies.” I’m going to get there early so I can find a seat.
–Nancy Walsh