THE INTENDED AND UNINTENDED CONSEQUENCES OF CLINICAL GUIDELINES

Purpose: First, we examine whether clinical guidelines, designed to improve health care and reduce disparities in clinical practice, are achieving their intended consequences. Second, we contemplate potential unintended consequences of clinical guidelines.

Method: As part of a factorial experiment we presented primary care doctors (n=192) with clinically authentic filmed vignettes of a “patient” with already diagnosed diabetes with emerging foot neuropathy. Their proposed clinical actions were compared with established practice guidelines for this clinical situation.

Result: There were important, consistent differences in the actions physician’s reported they would take depending on the “patient’s” socioeconomic status (SES). Specifically, physicians were more likely to perform the following for upper SES patients: ask questions regarding their medical history (adherence with diet, adherence with medications, exercise habits, previous neuropathy, and history of eye disease); recommend guideline suggested examinations (fundoscopic eye exam, check for ulcers, monofilament/vibration, foot pulses); order guideline recommended tests (fasting lipid, liver function, microalbuminuria, thyroid stimulating hormone); give referrals (ophthalmologist, podiatrist); and give advice (foot self exams, diet). After establishing the existence of consistent socioeconomic disparities in the proposed management of the case presented, we found that reported use of practice guidelines had no measurable effect towards their reduction (the intended consequence of clinical guidelines). However, one unintended consequence of clinical guidelines was that the reported use of practice guidelines appeared to precipitate more clinical actions, without eliminating documented disparities.

Conclusion: Consistent with other research we find clinical practice guidelines are not producing a principal intended result, reducing or eliminating the SES disparities in the treatment of diabetes evident in our experiment. Guideline adherent physicians in our study were more likely to perform nearly all of the clinical actions listed—19 out of the 20 specific actions of interest. In other words, use of guidelines appears to ensure that more of everything is done, without beneficially altering healthcare disparities.  We suggest an unintended consequence of the use of guidelines may be their contribution to ever increasing healthcare costs—an unintended consequence of clinical guidelines.