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EDITORIAL
Menopause: The Journal of The North American Menopause Society
Vol. 5, No. 2, pp.67-68
c 1998 The North American Menopause Society
The lead article (pp. 69-76) in this issue of Menopause marks the first time that The North American Menopause Society (NAMS) has published a formal consensus opinion regarding an issue of importance to health practitioners. In doing so, NAMS is responding to the critical need that exists for reliable, trustworthy, and accurate information on current scientific knowledge and health management. The Society recognizes that clinical standards, guidelines, and opinions have become an important component of these systems because they address elements of care that have been shown to be effective and standardize clinicians' approaches to management of health concerns and disease. With its multidisciplinary membership of experts from diverse yet related disciplines, NAMS is uniquely qualified to provide such guidance in the field of menopause.
The Society also understands that the field of menopause presents a special challenge, because related potential health issues span a myriad of diverse areas -- including both short-term effects (such as vasomotor symptoms and mood swings) and long-term effects (such as osteoporosis and cardiovascular disease). Moreover, the menopause transition is both a biological and a psychosocial passage.
The Society, however, wants to emphasize that this article, and those that will follow in future issues of Menopause, do not represent "practice standards" that would be codified and held up as standards by regulatory bodies and insurance agencies. The distinction was explained in a recent editorial in The Journal of the American Medical Association; three categories of practice parameters were defined: standards, guidelines, and options. The NAMS article falls somewhere between guidelines and options. We have chosen to call this first offering our "opinion."
Practice Parameters Explained
As explained in the JAMA editorial, standards represent medical practices that are associated with a well-defined outcome. In other words, if the clinician takes a certain action, then a certain consequence will follow in almost every case. Standards are supported by evidence from meticulous clinical trials, reflect a high degree of certainty, and should be followed in almost every circumstance.
Guidelines are associated with a set of outcomes, but not necessarily in every case. A certain action will usually produce a predictable consequence, but complicating factors may contribute to a different outcome. Guidelines represent a lower degree of certainty than do standards, and should therefore be used as an educational tool for supporting optimal practice, rather than enforcement.
Options, on the other hand, are opinion-based parameters that have yet to be supported by scientific evidence. Because of the high degree of uncertainly inherent in options, they are best used to stimulate discussion and promote future research.
Very few standards of care exist today, primarily because it is difficult to associate outcomes with one specific clinical practice. Certainly NAMS understands that the individual practicing clinician ultimately must assume the responsibility for meeting the needs of each individual patient. However, much of what occurs in health management can be encompassed by some practice parameters.
Selection of Topics for Consensus Opinions
The Society would like readers to understand that selection of topics for its consensus opinions does not imply a priority of need. The topic for this first opinion -- "Achieving Long-Term Continuance of Menopausal ERT/HRT" -- is undoubtedly one of great importance, but it is only one of several key issues that should be explored, and will be explored in future issues. NAMS wishes to clarify that, in this article, we are not offering suggestions on how providers could convince more women to initially accept hormone replacement therapy; rather, the scope of our article assumes that the patient has accepted therapy but for some reason(s) may not continue therapy. The article provides insights on factors that influence ERT/HRT continuance -- and also recommends areas of research that can help find more answers.
Summary
Considerable consultation with experts in the field has led to the conclusions reached in the article entitled "NAMS Consensus Opinion." Both published literature and clinical experience were evaluated by a panel of distinguished experts who convened to prepare their recommendations for the NAMS Board of Trustees. The article may not express the only valid approach to the topic, but readers can be assured that, like all official NAMS materials, it has been drafted and reviewed with the full benefit of the Society's considerable expertise. The Society is grateful to the panelists, and to Novartis Pharmaceuticals Corporation, whose unrestricted educational grant helped to defray costs associated with the conference.
We also wish to clarify that although the term "NAMS consensus" is used, one should not assume that every single member of the Society agrees with the published findings. Such a constraint would necessarily prevent any organization from publishing its opinions.
The Society hopes that the advice offered will be of assistance to the many different specialists charged with providing health care for the 4,000 women (in the U.S. alone) who are reaching menopause every day. We encourage your comments. You, our readers, will determine the way that future Society opinions will be presented.
Wulf H. Utian, MD, PhD
Executive Director
The North American Menopause Society
and Editor,
Menopause: The Journal of The North American Menopause Society
Reference
1. Eddy DM. Designing a practice policy: standards, guidelines, and options. JAMA 1990;263(22):3077-3084. |