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Medical guideline

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Not to be confused with Clinical pathway.
Plates vi & vii of the Edwin Smith Papyrus (around the 17th century BC), among the earliest medical guidelines

A medical guideline (also called a clinical guideline, standard treatment guideline, or clinical practice guideline) is a document with the aim of guiding decisions and criteria regarding diagnosis, management, and treatment in specific areas of healthcare. Such documents have been in use for thousands of years during the entire history of medicine. However, in contrast to previous approaches, which were often based on tradition or authority, modern medical guidelines are based on an examination of current evidence within the paradigm of evidence-based medicine.[1][2][3] They usually include summarized consensus statements on best practice in healthcare. A healthcare provider is obliged to know the medical guidelines of their profession, and has to decide whether to follow the recommendations of a guideline for an individual treatment.[4]

Background

Modern clinical guidelines identify, summarize and evaluate the highest quality evidence and most current data about prevention, diagnosis, prognosis, therapy including dosage of medications, risk/benefit and cost-effectiveness. Then they define the most important questions related to clinical practice and identify all possible decision options and their outcomes. Some guidelines contain decision or computation algorithms to be followed. Thus, they integrate the identified decision points and respective courses of action with the clinical judgement and experience of practitioners. Many guidelines place the treatment alternatives into classes to help providers in deciding which treatment to use.

Additional objectives of clinical guidelines are to standardize medical care, to raise quality of care, to reduce several kinds of risk (to the patient, to the healthcare provider, to medical insurers and health plans) and to achieve the best balance between cost and medical parameters such as effectiveness, specificity, sensitivity, resoluteness, etc. It has been demonstrated repeatedly that the use of guidelines by healthcare providers such as hospitals is an effective way of achieving the objectives listed above, although they are not the only ones.

Publication

Guidelines are usually produced at national or international levels by medical associations or governmental bodies, such as the United States Agency for Healthcare Research and Quality. Local healthcare providers may produce their own set of guidelines or adapt them from existing top-level guidelines. Healthcare payers such as insurers practicing utilization management also publish guidelines.[5]

Special computer software packages known as guideline execution engines have been developed to facilitate the use of medical guidelines in concert with an electronic medical record system. The Guideline Interchange Format (GLIF) is a computer representation format for clinical guidelines that can be used with such engines.[6]

The US and other countries maintain medical guideline clearinghouses. In the US, the National Guideline Clearinghouse maintains a catalog of high-quality guidelines published by various health and medical associations. In the United Kingdom, clinical practice guidelines are published primarily by the National Institute for Health and Care Excellence (NICE). In The Netherlands, two bodies—the Institute for Healthcare Improvement (CBO) and College of General Practitioners (NHG)—have published specialist and primary care guidelines, respectively. In Germany, the German Agency for Quality in Medicine (ÄZQ) coordinates a national program for disease management guidelines. All these organisations are now members of the Guidelines International Network (G-I-N), an international network of organisations and individuals involved in clinical practice guidelines.

Compliance

Checklists have been used in medical practice to attempt to ensure that clinical practice guidelines are followed. An example is the Surgical Safety Checklist developed for the World Health Organization by Dr. Atul Gawande.[7] According to a meta-analysis after introduction of the checklist mortality dropped by 23% and all complications by 40%, but further high-quality studies are required to make the meta-analysis more robust.[8] In the UK, a study on the implementation of a checklist for provision of medical care to elderly patients admitting to hospital found that the checklist highlighted limitations with frailty assessment in acute care and motivated teams to review routine practices, but that work is needed to understand whether and how checklists can be embedded in complex multidisciplinary care.[9]

Problems

Guidelines may lose their clinical relevance as they age and newer research emerges.[10] Even 20% of strong recommendations, especially when based on opinion rather than trials, from practice guidelines may be retracted.[11]

The New York Times reported in 2004 that some simple clinical practice guidelines are not routinely followed to the extent they might be.[12] It has been found that providing a nurse or other medical assistant with a checklist of recommended procedures can result in the attending physician being reminded in a timely manner regarding procedures that might have been overlooked.

Guidelines may have both methodological problems and conflict of interest.[13] As such, the quality of guidelines may vary substantially, especially for guidelines that are published on-line and have not had to follow methodological reporting standards often required by reputable clearinghouses.[14] Patients and caregivers are frequently excluded from clinical guidelines development, in part because there is a lack of guidance for how to include them in the process.[15]

Guidelines may make recommendations that are stronger than the supporting evidence.[16]

In response to many of these problems with traditional guidelines, the BMJ created a new series of trustworthy guidelines focused on the most pressing medical issues called BMJ Rapid Recommendations.[17]

Examples

See also

References

  1. ^ Burgers JS, Grol R, Klazinga NS, Mäkelä M, Zaat J (2003). "Towards evidence-based clinical practice: an international survey of 18 clinical guideline programs". Int J Qual Health Care. 15 (1): 31–45. doi:10.1093/intqhc/15.1.31. PMID 12630799.
  2. ^ AGREE Collaboration (2003). "Development and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: the AGREE project". Qual Saf Health Care. 12 (1): 18–23. doi:10.1136/qhc.12.1.18. PMC 1743672. PMID 12571340.
  3. ^ Institute of Medicine (edt.) Clinical practice guidelines we can trust. Washington DC, 2011
  4. ^ Council of Europe. Developing a methodology for drawing up guidelines on best medical practice. Recommendation Rec(2001)13 and explanatory memorandum. Strasbourg: Council of Europe Publishing, 2002.
  5. ^ Moses, Richard E.; Feld, Andrew D. (2008-01-01). "Legal risks of clinical practice guidelines". The American Journal of Gastroenterology. 103 (1): 7–11. doi:10.1111/j.1572-0241.2007.01399.x. ISSN 0002-9270. PMID 18184116. S2CID 11802118.
  6. ^ GLIF website
  7. ^ Haynes, Alex B.; Weiser, Thomas G.; Berry, William R.; Lipsitz, Stuart R.; Breizat, Abdel-Hadi S.; Dellinger, E. Patchen; Herbosa, Teodoro; Joseph, Sudhir; Kibatala, Pascience L.; Lapitan, Marie Carmela M.; Merry, Alan F.; Moorthy, Krishna; Reznick, Richard K.; Taylor, Bryce; Gawande, Atul A. (29 January 2009). "A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population" (PDF). New England Journal of Medicine. 360 (5): 491–499. doi:10.1056/NEJMsa0810119. PMID 19144931. S2CID 2639397.
  8. ^ Bergs, J.; Hellings, J.; Cleemput, I.; Zurel, Ö.; De Troyer, V.; Van Hiel, M.; Demeere, J.-L.; Claeys, D.; Vandijck, D. (February 2014). "Systematic review and meta-analysis of the effect of the World Health Organization surgical safety checklist on postoperative complications". British Journal of Surgery. 101 (3): 150–158. doi:10.1002/bjs.9381. PMID 24469615. S2CID 22951117.
  9. ^ Papoutsi, Chrysanthi; Poots, Alan; Clements, Jake; Wyrko, Zoe; Offord, Natalie; Reed, Julie E (5 January 2018). "Improving patient safety for older people in acute admissions: implementation of the Frailsafe checklist in 12 hospitals across the UK". Age and Ageing. 47 (2): 311–317. doi:10.1093/ageing/afx194. PMC 6016694. PMID 29315375.
  10. ^ 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. doi:10.1001/jama.286.12.1461. PMID 11572738.
  11. ^ Neuman MD; Goldstein JN; Cirullo MA; Schwartz JS (2014). "Durability of class I American College of Cardiology/American Heart Association clinical practice guideline recommendations". JAMA. 311 (20): 2092–100. doi:10.1001/jama.2014.4949. PMC 4346183. PMID 24867012.
  12. ^ Gina Kolata "Program Coaxes Hospitals to See Treatments Under Their Noses". The New York Times December 25, 2004.
  13. ^ Reames BN; Krell RW; Ponto SN; Wong SL (2013). "Critical evaluation of oncology clinical practice guidelines". J Clin Oncol. 31 (20): 2563–8. doi:10.1200/JCO.2012.46.8371. PMC 5073383. PMID 23752105.
  14. ^ Norberg MM, Turner MW, Rooke SE, Langton JM, Gates PJ (2012). "An Evaluation of Web-Based Clinical Practice Guidelines for Managing Problems Associated with Cannabis Use". J Med Internet Res. 14 (6): e169. doi:10.2196/jmir.2319. PMC 3799569. PMID 23249447.
  15. ^ Khodyakov, Dmitry; Kinnett, Kathi; Grant, Sean; Lucas, Ann; Martin, Ann; Denger, Brian; Peay, Holly; Coulter, Ian; Fink, Arlene (2017-04-28). "Engaging Patients and Caregivers Managing Rare Diseases to Improve the Methods of Clinical Guideline Development: A Research Protocol". JMIR Research Protocols. 6 (4): e57. doi:10.2196/resprot.6902. ISSN 1929-0748. PMC 5429434. PMID 28455279.
  16. ^ Brito JP; Domecq JP; Murad MH; Guyatt GH; et al. (2013). "The Endocrine Society guidelines: when the confidence cart goes before the evidence horse". J Clin Endocrinol Metab. 98 (8): 3246–52. doi:10.1210/jc.2013-1814. PMID 23783104.
  17. ^ a b Siemieniuk, Reed A; Agoritsas, Thomas; Macdonald, Helen; Guyatt, Gordon H; Brandt, Linn; Vandvik, Per O (28 September 2016). "Introduction to BMJ Rapid Recommendations". BMJ. 354 (i5191): i5191. doi:10.1136/bmj.i5191. ISSN 1756-1833. PMID 27680768. S2CID 32498374.
  18. ^ Wilson W; Taubert KA; Gewitz M; et al. (October 2007). "Prevention of infective endocarditis: guidelines from the American Heart Association". Circulation. 116 (15): 1736–54. doi:10.1161/CIRCULATIONAHA.106.183095. PMID 17446442.
  19. ^ Vandvik PO, Otto CM, Siemieniuk RA, Bagur R, Guyatt GH, Lytvyn L, Whitlock R, Vartdal T, Brieger D, Aertgeerts B, Price S, Foroutan F, Shapiro M, Mertz R, Spencer FA (2016). "Transcatheter or surgical aortic valve replacement for patients with severe, symptomatic, aortic stenosis at low to intermediate surgical risk: a clinical practice guideline". BMJ. 354: i5085. doi:10.1136/bmj.i5085. PMID 27680583.
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