What Clinical Guidelines Influence Your Medical Treatment?

Medical guidelines are used to ensure quality and consistency of medical care. If you have a health problem, you can be overwhelmed by mixed messages about your potential diagnoses or the best treatments you should use.

It’s important for you to know that your diagnosis and treatment isn’t random and isn’t based on biased opinions. Everyone on your medical team—doctors, nurses, therapists and other healthcare providers—should be licensed in the state and follow standard of care guidelines.

Your providers have taken the classes to get their degree, passed licensing exams, maintained continuing education, and are required to remain in good standing professionally. Usually, they are also members of at least one or more professional associations that provide updated medical news to healthcare providers. 

What Criteria Direct Your Diagnosis?

Your diagnosis might be fairly quick for certain conditions, especially if the illness affects you in a standard way. With nuanced medical conditions, your diagnosis can take time, like when the disease is known to manifest with a variety of effects. 

When it comes to medical diagnosis, some diseases, like a urinary tract infection, are diagnosed based on simple tests, like a urinalysis, that come back with a report of being positive or negative.

Other conditions, like poison ivy, are still fairly straightforward, but the diagnosis might be based on your history of exposure, your symptoms, and a visual examination of your skin. 

When Diagnosis Is Complex

For medical conditions that don’t have a positive or negative definition based on just one feature, clinical criteria can help your medical team decide whether your condition leans more towards a positive or negative diagnosis.

For instance, according to the American College of Rheumatology, systemic lupus erythematous (SLE), a fairly complex disorder, is diagnosed based on symptoms, physical examination findings, and a number of specialized tests.

And further distinctions can characterize a disease into different classifications that might require tailored treatments. Asthma is one such condition, as the National Heart, Lung and Blood Institute classifies asthma into categories defined by consideration of several different signs and symptoms.

Your medical team will use these diagnostic criteria to help identify the cause of your problem. But even when your complete clinical picture doesn’t neatly fit into any diagnosis, you are likely to have follow-up tests to see if things change, especially if your condition doesn’t clear up.

Qualifying for Treatments

Beyond diagnosis, you might wonder how your medical management is determined. Not getting treatment for a dangerous disease can be a major problem. But having risky treatment that isn’t indicated can be equally—or even more—harmful to your health.

An example of this type of situation is a stroke. There are lifesaving emergency treatments used for managing a stroke—like blood thinners and interventional procedures.

But these treatments can have serious side effects. And because strokes vary in their clinical presentation and prognosis, the guidance regarding therapy is very detailed. The American College of Cardiology provides direction for the acute management of stroke.

Some conditions might not be as urgent as a stroke, yet are still just as impactful to your well being. For example, lung cancer can often be life-threatening, but powerful treatments such as chemotherapy and radiation therapy can improve survival tremendously.

Guidelines such as those provided by the National Cancer Institute can help you and your healthcare provider talk about your options to make the decision that is safest and most beneficial for you. 

How Are Guidelines Made?

The guidelines for medical treatments are decided by a committee that’s usually selected from a group of highly experienced and qualified medical professionals. They don’t just base guidelines on their own gut feeling or even on their own experiences, however. They look to peer-reviewed research for evidence.

Using the available science, a guideline committee can learn which treatments work and which don't work. They can determine if certain groups of patients (such as children, pregnant women, or people who have kidney disease) might have a response that is different than others so the recommendations can be adjusted for that specific group.

After the guideline committee looks to peer-reviewed research for information, they create a proposed set of diagnostic or treatment standards. Often, members of the professional association are invited to review the proposed guidelines and to suggest changes if necessary.

Peer-Reviewed Research

Peer-reviewed research is a type of research in which scientists apply for national and local permission to conduct experiments by submitting their research plan in advance. Issues such as the safety and benefits of the study are typically included in the proposal.

The research is conducted, followed by analysis and preparing for publication:

• After the research is complete, the investigators provide their results to a scientific journal.
• A group of experts reviews the results to decide whether the research is reliable and worthy of publication.

The published peer-reviewed research then becomes part of the scientific body of evidence that is used in making medical decisions, such as medical treatment guidelines.

Guidelines and Insurance

Sometimes your medical payer might have a say in which diagnostic tests and treatments they will pay for. Keep in mind that these details are usually accessible to you when you sign up for your health plan.

Government payers (such as Medicare and Medicaid) and private health plans will usually cover diagnostic tests and treatments that are strongly recommended, but may vary in their payment restrictions when it comes to grey areas where the benefit isn’t clear.

Another thing to keep in mind is that there are often coverage tiers in which a person selects a plan that pays for some treatments but not others—and you might have selected a plan that doesn’t cover all of the diagnostic tests or treatments included in standard guidelines. This doesn’t mean that you can’t have the medical interventions—it just means that your health plan won’t pay for it. 

What Is Off-Label Treatment?

Most over the counter and prescription medications are approved for certain indications. This approval is granted by the Food and Drug Administration (FDA) and is based on an evaluation of research demonstrating its safety and efficacy for the given condition or conditions. 

Often, healthcare providers use a medication to treat a condition for which it isn’t FDA approved. This is described as off-label treatment and it is usually based on experience from many healthcare providers. It might be supported by peer-reviewed research and may even be included in the guidelines. 

What About Alternative Therapies?

Sometimes alternative therapies are considered beneficial and safe, but sometimes they are considered ineffective or even dangerous. It can be tricky to know if an alternative therapy is right for you if your healthcare provider didn’t specifically recommend it.

The key is to ask your healthcare provider and your alternative care practitioner (if you’re having a treatment like acupuncture for instance) all of your questions in advance and to see if you can find information that you trust about the treatment. 

A Word From Verywell 

With controversies about medical care, it can feel scary if you wonder if you are getting the unbiased care you need. Rest assured that there are guidelines and safety features built into the system to help standardize and optimize your care. Nevertheless, if you are ever concerned about any aspect of your care, don’t hesitate to speak up and ask for clarification or a second option.