Bangladesh is a country with a large population. The health care needs of this huge population are met by a plethora of health care workers many of whom are not even trained formally for this work (traditional healers). Even in those who are trained in formal medicine we find doctors with various academic background and training. There is an amulgation of medical degrees which is not seen anywhere else in the world. As a result the diagnostic and clinical approach to patient varies widely. This setup denies the patient the standard of care that he or she deserves. In this context clinical practice guidelines can play a major role in standard patient care. Clinical practice guidelines are systematically developed to assist practitioners’ and patients' decisions about appropriate health care for specific clinical circumstances. Many terms have been developed including practice guidelines, practice standards, practice parameters, practice policies, protocols, algorithms, and critical paths, but the collective purpose is the same - reduction in unnecessary variability of care. Historically it started in USA, from attempts to monitor quality of care and cost of care. Experimental Medical Review Organizations were started in USA in 1971 by the National Center for Health Services Research and Development, which provided grants to assess quality of care. Legislation was signed into law as part of the Omnibus Reconciliation Act of 1989, creating the Agency for Health Care Policy and Research (AHCPR) [1]. A guideline is a stepwise evaluation of a clinical diagnosis or management strategy that requires observations to be made, decisions to be considered, and actions to be taken. Processes used during development of guidelines include informal and formal consensus methods, evidence-based methods, and explicit methods. Informal consensus method leads to poor quality and have been largely abandoned. Formal consensus development, based on the delphi technique is a stepwise process leading to recommendations that reflect the extent of agreement amongst individuals. This technique is limited in that it does not rely on explicit linkage between recommendation and the quality of the evidence reviewed. Evidence based methods have emerged with specific rules defined to link recommendations and supporting evidence [2]. Basic Steps in Guideline Development [3], [4] have been standardized by various international bodies and may be implemented in our country with a few adjustments. There are still methodological problems that have been identified. These include the needs to further define consistent definitions, to avoid publication bias, to maintain sensitivity to evolution in scientific understanding, and to develop criteria for validity of clinical research methods. Economic factors affecting guideline development also need to be avoided and include specialist interests, payer interests, and the need to disclose economic self interests [5]. A final problem is the challenge of disseminating already written guidelines to physicians and presents a formidable task unto itself and adds to the large burden of new data and information practitioners already have available. Guidelines should, therefore, be viewed as broad templates to assist physicians or patients in various clinical circumstances [6]. Clinical practice guideline is becoming an important determinant of how medicine and surgery is practiced in Western societies. It is time that this strategy is also introduced in Bangladesh to reduce variability in care, improve quality, measure outcomes, and reduces costs. It is expected of such institution as BCPS, and the professional bodies like Society of Surgeons and Association of Physicians of Bangladesh to initiate and implement such clinical guidelines.Prof. Dr. Anisur RahmanSenior Consultant & CoordinatorDepartment of General and Laparoscopic SurgeryApollo Hospitals DhakaReferencesGosfield A. Clinical practice guidelines and the law: applications and implications. In: Health Law Handbook. New York: Clark Boardman Callaghan; 1994:67-99.Roper WL, Winkenwerder W, Hackharth GM, Krakauer H. Effectiveness in health care: an initiative to evaluate and improve medical practice. NEJM. 1988; 319:1197-1202.American Medical Association. Office of Quality Assurance. Attributes to Guide the Development of Practice Parameters. Chicago.Schoenbaum SC, Sundwall DN, Reqman D. Using Clinical Practice Guidelines to Evaluate Quality of Care. AHCPR 95-0045, 1995;1&2.Ayres JD. The Use and Abuse of Medical Practice Guidelines. J Legal Med. 1994; 15:421-443.Tunis SR, Hayward R, Wilson MC. Internists’ attitudes about clinical practice guidelines. Ann Intern Med. 1994; 120:956-963.DOI: 10.3329/pulse.v3i1.6542Pulse Vol.3(1) July 2009 p.3
Paradigm shift, metamorphosis of medical ethics, and the rise of bioethics
