Introduction To A New Series
Introduction To A New Series
EM Practice Guidelines Update was created to meet the need of emergency physicians to stay current with practice guidelines that can assist clinical decision-making in the emergency department. The practice guidelines will be drawn from a variety of specialty sources, will be analytically reviewed using a systematic approach, and will include an editorial commentary, if indicated. We hope this free, online, interactive publication will become a valued resource to our Emergency Medicine Practice subscribers, and will help facilitate best practice in emergency care. As always, we welcome your comments and feedback.
WHAT ARE PRACTICE GUIDELINES?
Practice guidelines are documents developed to assist clinical decision-making. They are intended to assimilate the large volume of knowledge available from both the literature and from expert opinion into strategies helpful in diagnostic, management, and resource utilization decision-making. Practice guidelines have been used as tools in quality assurance programs, in creating health care policy, in directing research agendas, and in medicolegal determinations.
In recent years, there has been a proliferation of practice guidelines (also referred to as "clinical policies" or "practice parameters"). Thousands are in existence, and though many are directly related to emergency practice, these recommendations often fail to reach the primary users. To facilitate practice guideline utilization, a National Guideline Clearinghouse (www.guideline.gov) has been established. Unfortunately, practice guideline posting is often delayed, so there continues to be a need for physicians to have timely access to current practice guidelines, especially those published outside of emergency medicine literature.
The methodologies used to develop practice guidelines are divided into 2 general categories: consensus-driven and evidence-based. A number of practice guidelines have used both methodologies, but evaluating guidelines involves understanding the rationale for why a practice guideline was developed and how the final recommendations were derived. Ideally, a practice guideline is developed to assist readers' comprehension and application of the literature available on a given subject and to provide sound recommendations based on the best available information.
Consensus practice guidelines: Consensus practice guidelines are formulated by a group of experts who assemble, discuss the issues at hand, and draw their conclusions based on those discussions. This process may or may not involve some degree of literature review. This approach to practice guideline development has been described as "global subjective judgment" and is highly susceptible to bias that enters the decision-making process.
Evidence-based practice guidelines: Evidence-based practice guidelines are the preferred method for guideline development. In this method, appropriate literature is reviewed by a panel experienced in reading the literature, and each piece of evidence is graded according to set criteria. Recommendations are then made based on the strength of available evidence.
Once a practice guideline is developed, its recommendations can be constructed into an implementation tool such as a "clinical pathway" or an "annotated algorithm" which takes into account the resources available; such a tool is incorporated into each issue of Emergency Medicine Practice.
Critically Assessing Practice Guidelines
Because of variations in practice guideline development methodology, it is necessary to critically assess a practice guideline before it is adopted. In order to do this, several questions must be asked:
1. Why was the topic chosen and are the objectives and goals clearly stated? The first step in evaluating the value of a clinical practice guideline is assessing why the topic was chosen (eg, to improve patient care, to lower cost, to support an organization's practice preference). Evaluating the funding source for potential conflict of interest can identify factors that may have biased the practice guideline's recommendations.
2. What are the credentials of the practice guideline's authors and do they have the expertise to competently assess the subject? Practice guideline development is a complex process that requires both clinical expertise and proficiency in the scientific process of evaluating the quality of research. Panel members should include both clinicians who understand the practice environment and scientists who can assist in properly evaluating the strength of evidence available in the literature. The creation of joint (multispecialty) task forces including all affected specialties helps to minimize this bias.
3. What methodology was used to generate the practice guideline's recommendations? The practice guideline should clearly define how it went about collecting the scientific evidence used in generating its recommendations. This process usually takes the form of a reference database search with explosion of terms as needed. The practice guideline must then describe the mechanism used in evaluating the literature reviewed and assigning it a strength of evidence level. Lastly, a description of how recommendations were generated is key, including the emphasis placed on consensus opinion when clear scientific evidence was not available. In general, consensus opinion alone is not sufficient to scientifically define a standard of care.
4. What is the format? The utility of a practice guideline in clinical practice is largely dependent on its format, which determines the readability, accessibility, and retrievability of information in the practice guideline. Certain topics are amenable to decision rule-making while other topics can only be addressed by case-based reasoning. Such topics may allow the development of evidence-based statements but may not be transformed into decision rules or algorithms. Full-text formats allow for ample justification but may be problematic when looking for a specific item if they are not extensively indexed. Algorithm formats are generally easy to follow but do not deal with complex decision-making.
5. Was the practice guideline field-tested or reviewed in clinical practice? A key component to a practice guideline is its relevance to clinical practice. Field testing and/or careful review by practicing physicians of a practice guideline during its development process can assist in evaluating its relevance. The endpoint in a management recommendation is multifactorial. Ideally, a practice guideline should take into consideration outcomes that are important to the patient, such as quality of life.
6. When was the practice guideline written, and is there a mechanism to keep it current? Clinical practice is constantly changing as new evidence becomes available. Practice guidelines can take years to develop and can become outdated quickly (such as the changing recommendations related to stroke management). Consequently, date of publication is important to check before accepting a recommendation of a practice guideline.
In conclusion, practice guideline development has been driven by a need to summarize the medical literature in a critical and constructive way. Recommendations made should allow for practice flexibility that is tailored to an individual patient's situation. Strict "standards of care" are rarely established and the format of grading recommendations based on strength of evidence serves to reinforce the fact that the practice of medicine is an art that must take into consideration a number of variables. From a medicolegal point of view, practice guidelines should be referenced only as a framework, and deviations from recommendations are appropriate when there is documentation of the clinician's decision-making process, tailored to meet the needs of the patient at hand.
By: Reuben Strayer, MD, Editor-In-Chief, Assistant Professor of Emergency Medicine, Mount Sinai School of Medicine, New York, NY