Frontline clinician scientists recommend more proactive guidelines to deal with pandemics

A new editorial written by clinical academics working on the frontline of the Covid-19 pandemic has warned that national guidelines need to adapt in the face of pandemics.

Published in The BMJ today (Friday), the article considers that guidance developed by national bodies was slow to appear during the first and second waves of the pandemic, leaving local providers unsupported when making many critical treatment decisions. Without national coordination, this encouraged inconsistent practices, unequal access to treatments and inefficient use of resources.

The authors, from St George's, University of London, write that by the time the National Institute for Health and Care Excellence (NICE) published a guideline on the management of Covid-19 on 23^rd March 2021, UK clinicians had managed more than 450,000 hospital admissions related to the disease.

Patients should be able to receive a high standard of care, irrespective of where they are treated. During the course of the pandemic, patients have been treated differently depending on the hospital they have been admitted to and the opinions of clinicians at a local level. We need swift guidance from national bodies that considers the scientific evidence for treatments, the resources available to provide these treatments on a country-wide level and the practicalities for allocating these resources. If we do not consider each of these elements, then this can lead to inequities in care across the country."

Dr Dipender Gill, Study First Author and Clinician Scientist, St George's, University of London

Delays in guidance, suggest the authors, led to considerable variability in treatment. For example, use of the immunosuppressants, tocilizumab and sarilumab to treat patients has varied. Recommendations from NICE on the use of these drugs were published in April 2021 - two months and 30,000 UK hospital admissions after the results from a pivotal trial were made available.

NICE recently announced a new 5-year strategy to provide faster access to treatments with dynamic guideline recommendations. The Institute intends to evolve guidance into modular, living recommendations that can be rapidly updated, rather than producing full guidelines over a longer time course. The authors of The BMJ editorial welcome this new approach from NICE, but urge the organization to maintain the strategy, and other professional bodies to act similarly.

Dr Andrew Hitchings, senior author of the article from St George's, University of London and an intensive care consultant, said, "The paradox is that when evidence is scarce or evolving, guideline producers would naturally prefer to wait for it to mature. But in the interim, local providers and clinicians are left making difficult decisions, often reaching different answers to the same questions. In a state of collective uncertainty, standardizing our practice around clear, timely guidance on the most difficult questions brings many benefits."

Dr Gill added, "The recent steps outlined by NICE in their new strategy are going to be critical in tackling future outbreaks and emerging diseases. We now need other guidance-producing organizations to step up to the plate and clinicians at the bedside to follow national guidelines as they come out to ensure equitable care for patients no matter where they are."