“ARE CHRONIC VENOUS DISEASE GUIDELINES ADAPTED
TO DAILY PRACTICE (medicographia volume 33 No. 3 2011)”
H. S. Yuwono,
Indonesia
Hendro Sudjono YUWONO,MD, PhD Hasan Sadikin General Hospital
Jalan Pasteur 38, Bandung 40161 INDONESIA
(e-mail: hsy47@bdg.centrin.net.id)
Phlebology has benefited from the general advance in vascular diagnostics and therapeutics achieved in the second half of the twentieth century. The lessons of multiple multicenter trials have been encapsulated in clinical guidelines that should accelerate the pace of clinical research by raising and standardizing the level of care worldwide, enabling new lessons to be learned more quickly, which can then be ploughed back into the recommendations to produce ever better informed and relevant updates.
Guidelines play a key socioeconomic role by standardizing best practice, ensuring that all patients with similar disease can expect to receive approximately similar treatment, and be reimbursed accordingly. They also encourage communication and cooperation between specialists, not only in the preparatory stages of elaborating the guidelines themselves, but also in encouraging their uptake by others, whether in journal articles, scientific meetings, or simply hospital case conferences and journal clubs. Guidelines provide a common descriptive language and a point of reference that allow specialists to compare like with like, rather than swap anecdotal, unextrapolative experiences, as tended to be the case in the past. In other words, guidelines are essential to scientific progress.
and, perhaps most importantly, they should be updated at regular intervals, ideally by a data collection program incorporated within the guidelines themselves. An important word of warning, however: guidelines must always be applicable to routine clinical practice. They cannot be feasible only in an academic or clinical trial setting. If so, they remain sterile and fail as drivers of progress. This, unfortunately, has been the fate of many guidelines. Time management issues, staffing levels, sociocultural setting,
economic and organizational environment1—all need to be taken into account if
guidelines are to fulfill their purpose.
Guidelines that are not informed by such considerations risk accusations of irrelevance, gathering dust on academia’s shelves. Some accusations go further, referring to potential limitations and possible patient harm. Patients on bed rest for more than 3 days at the Hasan Sadikin General Hospital (Bandung, Indonesia) did not benefit from antiplatelet agents: cases of deep vein thrombosis were confined almost entirely to gynecological patients with cancer.2
Elastic compression stockings are a mandatory precaution for reducing the risk of postthrombotic syndrome.3However, they find less favor among Indonesians than among inhabitants of more temperate climates. The stockings are difficult to wear in hot and sweaty conditions. This is an instance of a northern recommendation falling foul of a southern geographic location.
For more detailed information on this topic, we interviewed nine doctors treating chronic venous disease in four Bandung hospitals. Almost none ever follow the elastic compression stocking guideline. Only two sometimes implemented the guideline. This decision appeared to alienate all the doctors from the other recommendations in the guideline, with the result that they did not understand why they should follow any such guideline or feel obliged to do so. Instead, they manage their patients according to the relevant textbook and maintain that this produces acceptable results. In this instance, it could be concluded that despite all the arguments in favor of guidelines, there is little evidence of management failing without them._
References
1.Groll R. Implementation of evidence and guidelines in clinical practice: a new field of research.Int J Qual Health Care. 2000;12:455-456.
2. Prasetyo E. Deep vein thrombosis: Is malignancy the most dominant risk? Bandung,
Indonesia: School of Medicine, Pajajaran University; 2007.
3. Kolbach DN, Sandbrink MW, Hamulyak K, Neumann HA, Prins MH.
Non-pharmaceutical measures for prevention of post-thrombotic syndrome. Cochrane
