Patient Management Guidelines

Bonnie Weiner, MD, MSEC, MBA
Bonnie Weiner, MD, MSEC, MBA
What are patient management guidelines, and how are they set? In cardiology, guidelines are typically set by an organization when a sufficient body of evidence exists for the treatment of a specific disease state. Guidelines are also used as guiding principles for a certain procedure or procedural group, such as percutaneous intervention. A working group is then established that includes representatives from all of the major groups that have influence upon or interest in that particular area. The working group reviews available data and weighs it in terms of how helpful the data is, taking into account how well each trial was conducted. For example, large randomized clinical trials are rated the highest, while small registries and case reviews are rated the lowest. Final recommendations are made based on the quality of the available data and its consistency. If there are no clear data, then the working group comes up with a consensus. How are guidelines typically used by practitioners? Guidelines should be used to help practitioners determine how they should treat patients. Clearly, every patient is unique and may not represent the information that goes into the development of a guideline, so there is always an interpretation of how a specific guideline should be applied to a specific patient. But, in general, guidelines are used to help practitioners, as well as institutions, develop policies and procedures for dealing with patient groups. These guiding principles are meant to filter down to an individual patient as appropriate. When do guidelines usually get updated? Guidelines are typically updated when there has been a significant change in the available data, for example, a clinical update or policy change. A formal guideline update is a very long, laborious effort, so there must be an accumulation of data that modifies the standing guidelines. Sometimes this takes five years or more. What role does SCAI play in patient management guidelines? Our role is to provide quality guidance and education to our 4,000 members, all of whom are interventionalists. We take this role seriously and are trying to expand it so we can reach more of the people who take care of our patients. SCAI’s mission is to promote excellence in invasive and interventional cardiovascular medicine through physician education and representation, and advancement of quality standards to enhance patient care. We keep our members updated on guidelines and clinical information via mailings and our journal, Catheterization and Cardiovascular Interventions. SCAI has been at the forefront of providing guidance to physicians regarding the use of drug-eluting stents (DES). When did SCAI issue its first position statement on DES? SCAI issued its first position statement on DES in 2003, in preparation for the approval of DES in the United States. Leading up to the approval, it was clear there were many concerns on how to best implement this technology, which was better but more expensive than existing technologies. The goal of issuing the statement was to give interventional cardiologists guidance on how to evaluate available data and integrate DES into their practices. We issued another position statement in January 2007 emphasizing the importance of keeping patients with DES on dual anti-platelet agents for a minimum of 12 months. The major independent predictor of late-stent thrombosis, particularly in the first year, is premature cessation of dual anti-platelet agents. After one year, the protocol is not completely clear, because late thrombosis can occur despite a dual anti-platelet agent regimen. Can cath lab technologists and nurses use guidelines? Absolutely. Although guidelines are aimed at the physicians who are actually performing procedures, cath lab staff and nurses are critically important to our success. These individuals often have more opportunities to pass along information from guidelines to patients, for example, about dual anti-platelet agents, which can make a huge difference in patient outcomes. Sponsored by Boston Scientific Corporation.