Developing clinical guidelines

The methods of guideline development should ensure that treating patients according to guidelines will achieve the outcomes that are desired. This article presents a combination of the literature about guideline development and the results of our combined experience in guideline development in North America and Britain. It considers the 5 steps in the initial development of an evidence-based guideline.     

Evaluation of clinical practice guidelines.

Compared with the current focus on the development of clinical practice guidelines the effort devoted to their evaluation is meagre. Yet the ultimate success of guidelines depends on routine evaluation. Three types of evaluation are identified: evaluation of guidelines under development and before dissemination and implementation, evaluation of health care programs in which guidelines play a central role, and scientific evaluation, through studies that provide the scientific knowledge base for further evolution of guidelines. Identification of evaluation and program goals, evaluation design and a framework for evaluation planning are discussed.     

European guidelines for clinical management of abnormal cervical cytology, Part 2

The current paper presents the second part of chapter 6 of the second edition of the European Guidelines for Quality Assurance in Cervical Cancer Screening . The first part of the same chapter was published in a previous issue ( Cytopathology 2008;19:342–54). This part provides guidance on how to manage and treat women with histologically confirmed cervical intraepithelial neoplasia. The paper describes the characteristics, indications and possible complications of excisional and ablative treatment methods. The three options to monitor the outcome after treatment (repeat cytology, HPV testing and colposcopy) are discussed. Specific recommendations for particular clinical situations are provided: pregnancy, immuno-suppression, HIV infection, post-menopause, adolescence and cyto-colpo-histological disparity. The paper ends with recommendations for quality assurance in patient management and some general advice on how to communicate screening, diagnosis and treatment results to the woman concerned. Finally, a data collection form is attached.     

Developing clinical practice guidelines: target audiences, identifying topics for guidelines, guideline group composition and functioning and conflicts of interest

ABSTRACT: Clinical practice guidelines are one of the foundations of efforts to improve health care. In 1999, we authored a paper about methods to develop guidelines. Since it was published, the methods of guideline development have progressed both in terms of methods and necessary procedures and the context for guideline development has changed with the emergence of guideline clearing houses and large scale guideline production organisations (such as the UK National Institute for Health and Clinical Excellence). It therefore seems timely to, in a series of three articles, update and extend our earlier paper. In this first paper we discuss: the target audience(s) for guidelines and their use of guidelines; identifying topics for guidelines; guideline group composition (including consumer involvement) and the processes by which guideline groups function and the important procedural issue of managing conflicts of interest in guideline development.     

A discussion of the pediatric clinical guidelines

It is evident from both the AAO and AOA guideline position statements that a visual and eye examination is essential within the first few months of life. Thus, both groups recognize the importance of examining infants within the critical period of visual development. The adequacy of testing performed by lay screeners or primary care physicians to rule out all visual disorders is highly questionable. Photorefraction is a promising screening technique, but as yet needs to be validated by further study. The only adequate means of detecting early vision and eye disorders is through examination by an eye care professional. However, this conclusion immediately underscores the need for eye care professionals prepared to examine very young children. The primary eye care of children should not be considered the responsibility of a minority of ‘pediatric specialists’. Clinical techniques are currently available which would enable all practitioners to evaluate children in the first few months of life, a critical time for an initial evaluation. We believe it is essential for all eye care professionals to be trained in these basics of eye and vision care. The need for widespread pediatric training should be addressed when reviewing the clinical education of interns.Both guidelines yield valuable guidance and background information for the pediatric examination. The AOA guideline is more complete, and includes a useful bibliography. It is well researched, and should be particularly helpful to the newer practitioner. The AAO guideline provides less detailed guidance, and omits some newer and important examination techniques, such as preferential looking for visual acuity and spray application for administering drugs.The AOA and AAO pediatric clinical practice guidelines can serve as helpful examination tutorials for the practitioner. The guidelines do not address the decision making process of diagnosis and treatment options. The references included in the documents can help fill in the gaps, but would require a substantial commitment of time for research and study. We see the need for additional guidelines to help guide the process of difficult decision-making when the patient is ‘in the chair’. The publication of such second generation documents would serve eye care professionals in the total case management of the pediatric patient.