Clinical guidelines---the hidden costs

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Abstract
The publication of guidelines for statin treatment in the United Kingdom attracted criticism, particularly that no attempt had been made to assess the implications for resources associated with the guidelines. 1 2 The need to evaluate cost and clinical effectiveness in real terms before the widespread use of a treatment is frequently acknowledged.3 Unfortunately, these issues are rarely addressed in clinical guidelines, and there is little evidence that cost effectiveness in practice is considered in drawing up guidelines. 4 5 Surprisingly little consideration has been given to the role of guidelines in a healthcare system in which resources are constrained. 6 7 Cholesterol lowering drugs epitomise the problems that affect clinical guidelines in many areas. We consider here some unintended consequences from the development of guidelines (whether regulatory or … supposedly … advisory) that arise for those funding health care, doctors, and patients. ### Summary points Implementation of evidence based guidelines may limit doctors' discretion and the autonomy of local commissioners Guidelines allow narrow interest groups to impose their priorities on the health service Implications for resources and the real effects of proposals must be evaluated thoroughly if guidelines are to be of value Failure to do this may distort decision making in health care; this, in turn, can lead to unbalanced structures that do not serve the best interests of patients All clinical guidelines aim to promote “best practices” that improve the outcomes of treatment.8 This rests on two assumptions—firstly, that outcomes identified in clinical trials are reproducible in normal practice and, secondly, that rapid and universal adoption of an effective treatment leads to optimal treatment for the whole population. Guidelines place most weight on evidence generated in randomised controlled trials. Unfortunately, real life clinical practice, where resources are more restricted, patient compliance …