I am not ashamed to say that I love algorithms. They say a picture is worth a thousand words, well an algorithm must be worth at least that.
Medical algorithms, flow diagrams, decision trees—whatever you choose to call them—are useful tools that can be used to support clinical decision making. They can be used to guide a range of clinical conundrums, such as diagnosis, assessment of risk, or the selection of appropriate treatments. Most healthcare professionals simply do not have time to read every piece of evidence, or every page of every clinical guideline (let alone whimsical editorials like this one), which is why algorithms can be so useful. Many guidelines include algorithms that summarise the key recommendations in a simple, quick, and easy-to-use format. This issue of Guidelines in Practice includes a number of algorithms designed to support clinical decisions.
The most recent update to the British guideline on the management of asthma, developed by the British Thoracic Society (BTS) and the Scottish Intercollegiate Guidelines Network (SIGN), was published in July 2019. Dr Sinan Eccles discusses the revisions that are most relevant to primary care. The article covers how to conduct an in-depth review of a person’s asthma, indicators that can help to predict a patient’s risk of a future asthma attack, and updated recommendations about the pharmacological and non‑pharmacological management of asthma. Three useful algorithms from the BTS/SIGN guideline are included—a diagnostic algorithm, and algorithms that summarise the pharmacological management of asthma in adults and children. There is also a set of multiple-choice questions to test your knowledge after reading the article.
In August 2019, NICE published an updated guideline on the diagnosis and management of hypertension in adults—Professor Terry McCormack summarises the recommendations that primary care professionals need to know on. Following the update, there are changes to the cardiovascular disease risk level at which treatment for high blood pressure can be started, updated treatment criteria and targets, and new recommendations about assessing and managing severe hypertension. Alongside the guideline, NICE has developed a visual summary, which includes algorithms for the diagnosis and treatment of hypertension in adults and the choice of antihypertensive drug, monitoring treatment, and blood pressure targets.
The European Society of Cardiology (ESC) and the European Association for the Study of Diabetes (EASD) published an updated guideline on diabetes, pre-diabetes, and cardiovascular diseases in September 2019. Professor Peter Grant and Professor Francesco Cosentino describe the updated recommendations and discuss a new classification system for cardiovascular risk used by the ESC/EASD guideline, the cardiovascular safety and efficacy of new pharmacological therapies in the management of patients with diabetes, and how to individualise targets and treatments. Two algorithms are included: one describes the management of drug-naïve patients with type 2 diabetes, and the other the management of patients with type 2 diabetes who are already on metformin. Use the patient scenarios on to reflect on how you would manage different cases in line with the updated guidance.
Dr Kash Bhatti provides top tips for getting started with dermoscopy in primary care. Dr Bhatti describes how dermoscopy can help GPs to become confident in diagnosing benign skin lesions, and provides answers to common questions such as ‘How will dermoscopy help me?’, ‘How do I assess a skin lesion?’, and ‘How can I avoid missing a cancer?’. The Chaos and clues algorithm and the Prediction without pigment algorithm, included in the article, can be used to guide the triaging of lesions.
I am sometimes tempted to create and use algorithms to guide challenging real-life decisions: what to have for tea, what to wear, and maybe even who to vote for. What do you think of algorithms? Do you find them a useful adjunct to clinical guidelines, or do you feel they risk oversimplifying important clinical decisions? I also love tables, but I’ll save that for another editorial.
Gemma Lambert, Editor