Practice guidelines and the emergence of the “Yardstick”
We live in unsettled times. The fate of our health care system is up in the air, the majority of physicians are burned out, and our specialty’s traditional private practice model has become a less attractive option for young allergy/immunology specialists. Even practice parameters, the low-drama evidence-based tools that many of us refer to regularly, are changing dramatically. In addition to serving as a practical reference for practicing allergy/immunology specialists, practice parameters have gained increasing importance as tools used by third party payers. The Joint Task Force on Practice Parameters has worked hard to ensure these parameters are accepted by the National Guideline Clearinghouse (NGC), an organization that is part of the Agency of Healthcare Research and Quality of the U.S. Department of Health and Human Services. However, in response to a new mandate from the Institute of Medicine, the NGC has gradually changed its qualification criteria, including a “grade” system for defining the quality of evidence. The net effect of this evolution has been a drastic reduction in both the number of summary statements and the breadth of each practice parameter document.
The evolution of NGC criteria has arguably strengthened the credibility of our practice parameters. Although, much of the standard of care in our specialty – and indeed in all specialties – is based on a combination of evidence and best practice consensus that does not meet these new criteria and therefore will be left out of practice parameters. For example, using a course of prednisone to treat an acute asthma exacerbation is a standard practice that does not meet “grade” criteria and would not be permissible in a NGC document.
So what about a practical reference that will help practicing allergists with day-to-day clinical management decisions? Thanks to the vision of Bobby Lanier, MD, FACAAI and others involved with the College Vision 2020 strategic plan, the “Yardstick” concept emerged to provide practical, concise, evidence-based documents to assist with every day clinical decision-making. The first finished product of this vision – The Asthma Yardstick – was published in the Annals in February (Ann Allergy Asthma Immunol. 2017 Feb;118(2):133-142.e3). Led by Bradley Chipps, MD, FACAAI, the authors of this document specifically addressed important areas that are not included in other guidelines. For example, this Yardstick details how to conduct a sustained step-up in asthma therapy for patients with uncontrolled asthma.
The Asthma Yardstick is just the first of a series of Yardstick projects. Next will come the Atopic Dermatitis Yardstick, and there are plans for Yardsticks covering asthma “Step Down” management decisions and pediatric asthma management. Overall, this series has the potential to be a valuable addition to the educational tools supported by the College, especially in these changing times.
Stephen A. Tilles, MD, FACAAI