Hoarseness Guidelines Continue to Draw Scrutiny: Panel members question evidence-based criteria

LAS VEGAS—The newly adopted clinical practice guidelines (CPG) on hoarseness—and concerns that portions are overly simplistic and could harm care—took center stage here in a panel discussion at the Annual Meeting of the American Society of Pediatric Otolaryngology, part of the Combined Otolaryngology Spring Meetings held here April 28-May 2.

Panel members underscored their worries about the guidelines’ direction on laryngoscopy and said that the desire to set evidence-based criteria shouldn’t come at the expense of knowledge gained through years of experience.

The AAO-HNS/F published hoarseness guidelines in September

The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNS/F) published the guidelines in September (Otolaryngol Head Neck Surg. 2009;140:S4) in keeping with the trend, occurring across medicine, to try to make more treatment evidence-based.

Lucian Sulica, MD, director of voice disorders/laryngology at Weill Cornell Medical College in New York City, said that the published articles on which the guidelines are supposed to be based don’t represent the sum total of what is known about a disorder. “There is really not a substitute for common clinical sense here,” he said. “Information is not the same as knowledge. And the lack of published information is not a lack of knowledge.”

He added that it was “a big problem” that the guidelines did not meet the same peer review standards as the doctors in his audience had to meet for any of their own published papers.

Michael Johns, MD, director of the Emory Voice Center, added, “I think a lot of the troubles that are present in the CPG could have been circumvented by a more patient peer-review process.”

Academy Response

Gavin Setzen, MD, chair of the AAO-HNS Board of Governors, has suggested that such an assessment of the guidelines might be an overreaction. “The otolaryngologist must make a clinical judgment based upon the history and physical findings at the time of initial evaluation,” he said, emphasizing that the guidelines do not “supersede clinical judgment.”

Guideline authors have said that all the comments received about the proposals were considered, even though not all were acted upon.

In a session that association members said was considerably more subdued than the discussions at the Academy when the guidelines were set, David Eibling, MD, chair of the AAO-HNS’ Geriatric Otolaryngology Committee, said he understood the desire for such guidelines.

He shared a chart that showed skyrocketing health care costs in Miami, while in other places, such as Salem, Oregon, they were almost flat. “You have to believe that figures like this make the oversight agencies nuts,” he said, adding that the variation is due to use of discretionary services where evidence is weak. “Hence, the push to establish clinical practical guidelines to standardize care.”