Guidelines and clinical practice: Myth or reality? - Reality

There are two situations in which guidelines are of use to the clinician. The first occurs when there are clear diagnostic or therapeutic modalities that are inappropriately used. With regard to chronic obstructive pulmonary disease (COPD), this clearly pertains. Evidence suggests that the diagnosis of COPD, although straightforward and readily obtained by simple spirometry, is inadequately accomplished in both the USA and Europe. As a result, a large number of individuals with COPD are undiagnosed. Conversely, the diagnosis of COPD, which is often made in the absence of spirometry, is quite frequently incorrect. Application of spirometry to establish the diagnosis of COPD in subjects at risk, as recommended by guidelines, would address this diagnostic issue. Similarly, although rehabilitation for COPD patients is widely recognized as beneficial in evidence-based guidelines, its application is often inadequate. The availability of guidelines may help optimize application of appropriate therapies in a population. In addition, guidelines can help provide a framework for the clinician when application of a diagnostic or therapeutic modality is uncertain. For example, inhaled corticosteroids have measurable benefits on airflow, exacerbation frequency and mortality in chronic obstructive pulmonary disease. How they should be used clinically, however, is a matter of some judgment. Guidelines that use evidence when available and expert opinion when necessary can help inform clinician judgment. Guidelines, therefore, can help optimize diagnosis and therapy and, therefore, are an important tool for the clinician.