Clinical practice guideline

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Clinical practice guidelines are defined as "Directions or principles presenting current or future rules of policy for assisting health care practitioners in patient care decisions regarding diagnosis, therapy, or related clinical circumstances. The guidelines may be developed by government agencies at any level, institutions, professional societies, governing boards, or by the convening of expert panels. The guidelines form a basis for the evaluation of all aspects of health care and delivery."[1]

Clinical practice guidelines were initially encouraged by the Institute of Medicine in 1990.[2]

Problems with guidelines

Guidelines may have trouble with both validity and readability.[3] Even guidelines that are technically well-done may not be acceptable to clinicians.[4]

A structured comparison of clinical practice guidelines for the diabetes mellitus type 2 found variation in guideline quality with the best guideline being produced by the United Kingdom National Institute for Health and Clinical Excellence.[5]

Validity

Two important attributes of a practice guideline are:[6]

  1. Credibility to a range of stakeholders including clinicians, patients, and policy makers.
  2. The developers are accountable for their conclusions by using a process that is open, documented, and reproducible.

Because of concerns about the quality and validity of some practice guidelines[7][8], standards have been developed in both their reporting[9][10] and assessment.[11][12]

Applicability

Guidelines are usually developed for the care of a single disease; consequently, guidelines may direct care that is contrary to the overall well being of a patient with multiple other diseases.[13]

Readability

Guidelines can be very difficult to read which may contribute to lack of impact.[14] For this reason, some are now written with the inverse pyramid structure.[15][16]

Durability

Guidelines may loose their clinical relevance as they age and newer research emerges.[17]

Effectiveness

The effect of publication

The publication of clinical practice guidelines do not always influence health care[18][12] or take several years to do so.[19] Balanced against this is that guidelines may be out-of-date after an average of three years.[17]


Other measures to increase effect

The more modalities used to implement a guideline, the more impact the guideline will have.[20]

In addition, a systematic review of organizational interventions to improve the quality of care of diabetes mellitus type 2 suggests that interventions based on complexity science will be more successful.[21]

Finding published clinical practice guidelines

For guidelines published in the United States the National Guidelines Clearinghouse republishes many guidelines in a standardized format.

Guidelines can also be located at PubMed by searching for the publication type 'practice guideline'.[22] In addition, the Hedges Team has published a MEDLINE search strategy.[23]

References

  1. ↑ National Library of Medicine. Clinical practice guidelines. Retrieved on 2007-10-19.
  2. ↑ Lohr, Kathleen N.; Grossman, Jerome H.; Field, Marilyn J. (1990). Clinical practice guidelines: directions for a new program. Washington, D.C: National Academy Press. ISBN 0-309-04346-8. 
  3. ↑ Dartnell J, Hemming M, Collier J, Ollenschlaeger G (2007). "Putting evidence into context: some advice for guideline writers". Evidence-based medicine 12 (5): 130–2. DOI:10.1136/ebm.12.5.130-a. PMID 17909225. Research Blogging.
  4. ↑ Nuckols TK, Lim YW, Wynn BO, et al (2007). "Rigorous Development does not Ensure that Guidelines are Acceptable to a Panel of Knowledgeable Providers". J Gen Intern Med. DOI:10.1007/s11606-007-0440-9. PMID 18030541. Research Blogging.
  5. ↑ Qaseem A, Vijan S, Snow V, Cross JT, Weiss KB, Owens DK (September 2007). "Glycemic control and type 2 diabetes mellitus: the optimal hemoglobin A1c targets. A guidance statement from the American College of Physicians". Annals of internal medicine 147 (6): 417–22. PMID 17876024. [e]
  6. ↑ Mulrow CD, Lohr KN (2001). "Proof and policy from medical research evidence". Journal of health politics, policy and law 26 (2): 249–66. PMID 11330080. [e]
  7. ↑ Shaneyfelt TM, Mayo-Smith MF, Rothwangl J (1999). "Are guidelines following guidelines? The methodological quality of clinical practice guidelines in the peer-reviewed medical literature". JAMA 281 (20): 1900–5. PMID 10349893. [e]
  8. ↑ Grilli R, Magrini N, Penna A, Mura G, Liberati A (2000). "Practice guidelines developed by specialty societies: the need for a critical appraisal". Lancet 355 (9198): 103–6. DOI:10.1016/S0140-6736(99)02171-6. PMID 10675167. Research Blogging.
  9. ↑ Shiffman RN, Shekelle P, Overhage JM, Slutsky J, Grimshaw J, Deshpande AM (2003). "Standardized reporting of clinical practice guidelines: a proposal from the Conference on Guideline Standardization". Ann. Intern. Med. 139 (6): 493–8. PMID 13679327. [e]
  10. ↑ Hayward RS, Wilson MC, Tunis SR, Bass EB, Rubin HR, Haynes RB (1993). "More informative abstracts of articles describing clinical practice guidelines". Ann. Intern. Med. 118 (9): 731–7. PMID 8460861. [e]
  11. ↑ AGREE Collaboration (2003). "Development and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: the AGREE project". Quality & safety in health care 12 (1): 18–23. PMID 12571340. [e]
  12. ↑ 12.0 12.1 Atkins D, Best D, Briss PA, et al for the GRADE Working Group. (2004). "Grading quality of evidence and strength of recommendations". BMJ 328 (7454): 1490. DOI:10.1136/bmj.328.7454.1490. PMID 15205295. Research Blogging. PubMed Central Cite error: Invalid <ref> tag; name "pmid15205295" defined multiple times with different content
  13. ↑ Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW (2005). "Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance". JAMA 294 (6): 716–24. DOI:10.1001/jama.294.6.716. PMID 16091574. Research Blogging.
  14. ↑ Grol R, Dalhuijsen J, Thomas S, Veld C, Rutten G, Mokkink H (1998). "Attributes of clinical guidelines that influence use of guidelines in general practice: observational study". BMJ 317 (7162): 858–61. PMID 9748183. [e]
  15. ↑ Nielsen J. Writing Inverted Pyramids in Cyberspace (Alertbox). Retrieved on 2007-10-19.
  16. ↑ Barton MB, Miller T, Wolff T, et al (2007). "How to read the new recommendation statement: methods update from the U.S. Preventive Services Task Force". Ann. Intern. Med. 147 (2): 123–7. PMID 17576997. [e]
  17. ↑ 17.0 17.1 Shekelle PG, Ortiz E, Rhodes S, et al (2001). "Validity of the Agency for Healthcare Research and Quality clinical practice guidelines: how quickly do guidelines become outdated?". JAMA 286 (12): 1461–7. PMID 11572738. [e]
  18. ↑ Cabana MD, Rand CS, Powe NR, et al (1999). "Why don't physicians follow clinical practice guidelines? A framework for improvement". JAMA 282 (15): 1458–65. PMID 10535437. [e]
  19. ↑ Lomas J, Sisk JE, Stocking B (1993). "From evidence to practice in the United States, the United Kingdom, and Canada". The Milbank quarterly 71 (3): 405–10. PMID 8413068. [e]
  20. ↑ Yealy DM, Auble TE, Stone RA, et al (2005). "Effect of increasing the intensity of implementing pneumonia guidelines: a randomized, controlled trial". Ann. Intern. Med. 143 (12): 881-94. PMID 16365469. [e]
  21. ↑ Leykum LK et al. (2007). "Organizational interventions employing principles of complexity science have improved outcomes for patients with Type II diabetes". Implementation Science : IS 2: 28. DOI:10.1186/1748-5908-2-28. PMID 17725834. Research Blogging.
  22. ↑ Anonymous (Nov–Dec 2007). MEDLINE Data Changes - 2008. NLM Technical Bulletin. National Library of Medicine. Retrieved on 2008-03-19.
  23. ↑ Wilczynski NL, Haynes RB, Lavis JN, Ramkissoonsingh R, Arnold-Oatley AE (2004). "Optimal search strategies for detecting health services research studies in MEDLINE". CMAJ 171 (10): 1179-85. DOI:10.1503/cmaj.1040512. PMID 15534310. Research Blogging.

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