Developing clinical practice guidelines: reviewing, reporting, and publishing guidelines; updating guidelines; and the emerging issues of enhancing guideline implementability and accounting for comorbid conditions in guideline development

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 third paper we discuss the issues of: reviewing, reporting, and publishing guidelines; updating guidelines; and the two emerging issues of enhancing guideline implementability and how guideline developers should approach dealing with the issue of patients who will be the subject of guidelines having co-morbid conditions.     

Clinical guidelines contribute to the health inequities experienced by individuals with intellectual disabilities

ABSTRACT: BACKGROUND: Clinical practice guidelines are developed to improve the quality of healthcare. However, clinical guidelines may contribute to health inequities experienced by disadvantaged groups. This study uses an equity lens developed by the International Clinical Epidemiology Network (INCLEN) to examine how well clinical guidelines address inequities experienced by individuals with intellectual disabilities. METHODS: Nine health problems relevant to the health inequities experienced by persons with intellectual disabilities were selected. Clinical guidelines on these disorders were identified from across the world. The INCLEN equity lens was used as the basis for a purposedesigned, semistructured data collection tool. Two raters independently examined each guideline and completed the data collection tool. The data extracted by each rater were discussed at a research group consensus conference and agreement was reached on a final equity lens rating for each guideline. RESULTS: Thirty-six guidelines were identified, one of which (2.8%) explicitly excluded persons with intellectual disabilities. Of the remaining 35, six (17.1%) met the first criterion of the equity lens, identifying persons with intellectual disabilities at high risk for the specific health problem. Eight guidelines (22.9%) contained any content on intellectual disabilities. Six guidelines addressed the fourth equity lens criterion, by giving specific consideration to the barriers to implementation of the guideline in disadvantaged populations. There were no guidelines that addressed the second, third, and fifth equity lens criteria. CONCLUSIONS: The equity lens is a useful tool to systematically examine whether clinical guidelines address the health needs and inequities experienced by disadvantaged groups. Clinical guidelines are likely to further widen the health inequities experienced by persons with intellectual disabilities, and other disadvantaged groups, by being preferentially advantageous to the general population. There is a need to systematically incorporate methods to consider disadvantaged population groups into the processes used to develop clinical guidelines.     

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.     

A critical appraisal of guidelines for the management of knee osteoarthritis using Appraisal of Guidelines Research and Evaluation criteria

Clinical practice guidelines have been elaborated to summarize evidence related to the management of knee osteoarthritis and to facilitate uptake of evidence-based knowledge by clinicians. The objectives of the present review were summarizing the recommendations of existing guidelines on knee osteoarthritis, and assessing the quality of the guidelines using a standardized and validated instrument--the Appraisal of Guidelines Research and Evaluation (AGREE) tool. Internet medical literature databases from 2001 to 2006 were searched for guidelines, with six guidelines being identified. Thirteen clinician researchers participated in the review. Each reviewer was trained in the AGREE instrument. The guidelines were distributed to four groups of three or four reviewers, each group reviewing one guideline with the exception of one group that reviewed two guidelines. One independent evaluator reviewed all guidelines. All guidelines effectively addressed only a minority of AGREE domains. Clarity/presentation was effectively addressed in three out of six guidelines, scope/purpose and rigour of development in two guidelines, editorial independence in one guideline, and stakeholder involvement and applicability in none. The clinical management recommendation tended to be similar among guidelines, although interventions addressed varied. Acetaminophen was recommended for initial pain treatment, combined with exercise and education. Nonsteroidal anti-inflammatory drugs were recommended if acetaminophen failed to control pain, but cautiously because of gastrointestinal risks. Surgery was recommended in the presence of persistent pain and disability. Education and activity management interventions were superficially addressed in most guidelines. Guideline creators should use the AGREE criteria when developing guidelines. Innovative and effective methods of knowledge translation to health professionals are needed.     

Recent advances in research relevant to electric and magnetic field exposure guidelines

Limits on exposures to extremely low-frequency electric fields, magnetic fields and contact currents, designated as voluntary guidelines or standards by several organizations worldwide, are specified so as to minimize the possibility of neural stimulation. The limits, which we refer to as guidelines, derive from "basic restrictions" either on electric fields or current density within tissue, or on avoidance of annoying or startling interactions that may be experienced with spark discharge or contact current. Further, the guidelines specify more conservative permissible doses and exposure levels for the general public than for exposures in controlled environments, which most typically involve occupational settings. In 2001 we published an update on guideline science. This paper covers more recent developments that are relevant to the formulation and implementation of the next generation of guidelines. The paper deals with neurostimulation thresholds and the relevance of magnetophosphenes to setting guideline levels; dosimetry associated with contact current benchmarked against basic restrictions; tissue and cellular dosimetry from spark discharge; assessment of exposures to high electric fields in realistic situations (e.g., line worker in a transmission tower); a simplified approach to magnetic field assessment in non-uniform magnetic fields; and a quantitative approach to sampling workplace exposure for assessing compliance.     

Evaluation of evidence-based literature and formulation of recommendations for the clinical preventive guidelines for immigrants and refugees in Canada

Background:

This article describes the evidence review and guideline development method developed for the Clinical Preventive Guidelines for Immigrants and Refugees in Canada by the Canadian Collaboration for Immigrant and Refugee Health Guideline Committee.

Methods:

The Appraisal of Guidelines for Research and Evaluation (AGREE) best-practice framework was combined with the recently developed Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to produce evidence-based clinical guidelines for immigrants and refugees in Canada.

Results:

A systematic approach was designed to produce the evidence reviews and apply the GRADE approach, including building on evidence from previous systematic reviews, searching for and comparing evidence between general and specific immigrant populations, and applying the GRADE criteria for making recommendations. This method was used for priority health conditions that had been selected by practitioners caring for immigrants and refugees in Canada.

Interpretation:

This article outlines the 14-step method that was defined to standardize the guideline development process for each priority health condition.Primary care practitioners who care for recently arrived immigrants and refugees have raised concerns over the lack of evidence-based guidelines for clinical prevention, noting that it is not always clear whether current recommendations made for the general population in Canada can be generalized to this population. In 2006, the Canadian Collaboration for Immigrant and Refugee Health (CCIRH) Guideline Committee was formed to address this issue by first identifying the top-priority health conditions for this population. The group of 20 health conditions identified was very diverse ranging from infectious disease to chronic conditions including depression. The challenge was creating a rigorous interdisciplinary process and then to generate pragmatic recommendations. This document outlines the systematic approach designed to produce the evidence reviews.A variety of methods is used for developing clinical guidelines and practice recommendations.¹ We used the recently developed approach of moving away from recommendations classified by letters and numbers to the simplified classification system recommended by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group² and applied this to clinical preventive actions. Our guideline development process followed the Appraisal of Guidelines Research & Evaluation (AGREE) instrument (www.agreetrust.org), which is recognized internationally as providing best-practice criteria for evidence-based guideline development.We developed the recommendations on the basis of a pre-specified process overseen by the CCIRH Guideline Committee. Defining a methods process ensured that each guideline was developed in a systematic, reproducible manner and was based on the best evidence available. This process was based on existing guidelines including the Canadian Medical Association Journal handbook on developing clinical practice guidelines¹ and the ADAPTE framework for adapting existing guidelines.³ Our process emphasized identifying immigrant- and refugee-specific evidence on efficacy and population characteristics from guidelines, systematic reviews and primary studies. When immigrant- and refugee-specific evidence was unavailable, we used specific criteria, adapted from the Cochrane Handbook,⁴ to judge how this evidence applied to our intended target population.Conditions considered most important by practitioners caring for immigrants and refugees in Canada were assigned to groups of content experts to develop evidence reviews with clinical conclusions for recent immigrants and refugees to Canada using a logic model and following a structured 14-step process. The guidelines focus on clinical care gaps¹ during the “health settlement period,” which we define as the first five years of residence in a new country for an immigrant or refugee. This is the time in which health practitioners are likely to have initial contact with this population and the time during which stressors from one’s country of origin and country of settlement are most likely to manifest. Immigrants and refugees are thus grouped together by this organizing period of resettlement; however, the heterogeneity, complexities, and differences between and within these groups were recognized throughout the process.In our process, we emphasized making clinically relevant recommendations and establishing an extension to existing guidelines rather than a replacement or revision.     

Current guidelines have limited applicability to patients with comorbid conditions: a systematic analysis of evidence-based guidelines

Background

Guidelines traditionally focus on the diagnosis and treatment of single diseases. As almost half of the patients with a chronic disease have more than one disease, the applicability of guidelines may be limited. The aim of this study was to assess the extent that guidelines address comorbidity and to assess the supporting evidence of recommendations related to comorbidity.

Methodology/Principal Findings

We conducted a systematic analysis of evidence-based guidelines focusing on four highly prevalent chronic conditions with a high impact on quality of life: chronic obstructive pulmonary disease, depressive disorder, diabetes mellitus type 2, and osteoarthritis. Data were abstracted from each guideline on the extent that comorbidity was addressed (general comments, specific recommendations), the type of comorbidity discussed (concordant, discordant), and the supporting evidence of the comorbidity-related recommendations (level of evidence, translation of evidence). Of the 20 guidelines, 17 (85%) addressed the issue of comorbidity and 14 (70%) provided specific recommendations on comorbidity. In general, the guidelines included few recommendations on patients with comorbidity (mean 3 recommendations per guideline, range 0 to 26). Of the 59 comorbidity-related recommendations provided, 46 (78%) addressed concordant comorbidities, 8 (14%) discordant comorbidities, and for 5 (8%) the type of comorbidity was not specified. The strength of the supporting evidence was moderate for 25% (15/59) and low for 37% (22/59) of the recommendations. In addition, for 73% (43/59) of the recommendations the evidence was not adequately translated into the guidelines.

Conclusions/Significance

Our study showed that the applicability of current evidence-based guidelines to patients with comorbid conditions is limited. Most guidelines do not provide explicit guidance on treatment of patients with comorbidity, particularly for discordant combinations. Guidelines should be more explicit about the applicability of their recommendations to patients with comorbidity. Future clinical trials should also include patients with the most prevalent combinations of chronic conditions.     

Breaking new ground: challenging existing asthma guidelines

Background

While we have international guidelines and various national guidelines for asthma diagnosis and management, asthma remains poorly controlled in many children and adults. In this paper we review the limitations of current asthma guidelines and describe important issues and remaining questions regarding asthma guidelines for use, particularly in primary care.

Discussion

Clinical practice guidelines based on evidence from randomized controlled trials are considered the most rigorous and accurate. Current evidence-based guidelines are written predominantly from the perspective of the patient with a clear-cut asthma diagnosis, however, and tend not to consider the heterogeneity of asthma or to accommodate individual patient variations in response to treatment or their needs, differences in practice settings, or local differences in availability and cost of therapies. The results of randomized controlled trials, which are designed to establish efficacy of treatment under ideal conditions, may not apply to 'real-world' clinical practice, where patients are unselected, monitoring is less frequent, and effectiveness – the benefit of treatment in routine clinical practice – is the most relevant outcome. Moreover, most guidelines see asthma in isolation rather than considering other factors that may impact on asthma and response to asthma therapy, particularly age, allergic rhinitis, cigarette smoking, adherence, and genetic factors. When these links are recognized, guidelines rarely provide practical recommendations for treatment in these scenarios. Finally, there is some evidence that general practitioners are not convinced of the applicability of asthma guidelines to their practice settings, especially when those writing the guidelines principally work in specialist practice.

Conclusion

Developing country-specific guidelines or, ideally, local guidelines could provide more practical solutions for asthma care and could account for regional factors that influence patient choice and adherence to therapy. Pragmatic clinical trials and well-designed observational trials are needed in addition to randomized controlled trials to assess real-world effectiveness of therapies, and such evidence needs also to be considered by guideline writers. Finally, practical tools to facilitate the diagnosis and assessment of asthma and factors responsible for poor control, such as associated allergic rhinitis, limited adherence, and smoking behavior, are needed to supplement treatment information provided in clinical practice guidelines for asthma.

     

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.     

New generation water quality guidelines for ecosystem protection

1. Water quality guidelines are important for the management of water resources. Initially, guidelines focused on quality for domestic drinking water and for agricultural, recreational and industrial purposes. More recently, the emphasis has been on ecosystem protection, as well. 2. This paper discusses the key elements of new risk-based water quality guidelines being developed in Australia and New Zealand, that should lead to more effective management and protection of aquatic ecosystems. 3. There are three essential elements to this new approach: (i) it is ecosystem-based— ideally the guidelines should be, as far as possible, ecosystem-specific; (ii) it is issue-based— the guidelines should focus on the actual issues or problems caused by physical, chemical and biological stressors rather than on the individual indicators, as at present; and (iii) it is risk-based. There is generally great difficulty in deciding whether adverse biological effects will result from various stressors added to an ecosystem. The new approach develops guideline ‘packages’ for each issue and, where possible, for each ecosystem type. Each ‘package’ consists of specified key performance indicators, trigger levels for these indicators (that is, levels which indicate the degree of risk that adverse biological effects may occur), and for high risk situations (where trigger levels are exceeded) a protocol for considering the effect of ecosystem-specific factors in reducing (or enhancing) the biological effects. 4. This paper presents a case study related to a highly relevant aquatic ecosystem issue in Australia, namely the excessive growth of cyanobacteria (blue-green algal blooms), to illustrate how the new risk-based guidelines might be applied.     

Appraisal of WHO Guidelines in Maternal Health Using the AGREE II Assessment Tool

In 2007, the World Health Organization (WHO) received a criticism for a lack of transparency and systematic methods in the development of guidelines, which were at that time perceived as substantially driven by expert opinion. In this paper we assessed the quality of maternal and perinatal health guidelines developed since then. We used the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool to evaluate the quality of methodological rigour and transparency of four different WHO guidelines published between 2007 and 2011. Our findings showed high scores among the most recent guidelines on maternal and perinatal health suggesting higher quality. However, there is still potential for improvement, especially in including different stakeholder views, transparency of guidelines regarding the role of the funding body and presentation of the guideline document.     

Laboratory assays evaluate the influence of physical guidelines on subterranean termite (Isoptera: Rhinotermitidae) tunneling, bait discovery, and consumption

Laboratory assays were conducted to determine whether physical guidelines could direct subterranean termite foraging behavior. Several materials (wood, plastics, and wood thermoplastic composites) were evaluated for their potential to serve as termite guidelines. Termite tunneling along the different types of guidelines was measured. The proportion of baits discovered when connected by a guideline was compared with the proportion of unconnected baits discovered. Termite consumption of baits also was quantified. Assay results indicated that the termites did not respond to all guideline materials in the same way. Termites built significantly longer tunnels along wood guidelines than they did along any of the plastic guidelines tested. However, tunnel length along the wood and the wood thermoplastic composites was not significantly different. The probability of two baits being discovered when they were connected by wood guidelines was significantly greater than when the baits were connected by plastic guidelines or left unconnected (no guideline). Pairs of baits connected by wood thermoplastic composites were also significantly more likely to be discovered than unconnected baits. Bait consumption was not enhanced by the presence of the guidelines. It is likely that guidelines made of wood competed with the baits as a termite food resource.     

Guidelines for Guidelines: Are They Up to the Task? A Comparative Assessment of Clinical Practice Guideline Development Handbooks

Objectives

We conducted a comparative review of clinical practice guideline development handbooks. We aimed to identify the main guideline development tasks, assign weights to the importance of each task using expert opinions and identify the handbooks that provided a comprehensive coverage of the tasks.

Methods

We systematically searched and included handbooks published (in English language) by national, international or professional bodies responsible for evidenced-based guideline development. We reviewed the handbooks to identify the main guideline development tasks and scored each handbook for each task from 0 (the handbook did not mention the task) to 2 (the task suitably addressed and explained), and calculated a weighted score for each handbook. The tasks included in over 75% of the handbooks were considered as ‘necessary’ tasks.

Result

Nineteen guideline development handbooks and twenty seven main tasks were identified. The guideline handbooks’ weighted scores ranged from 100 to 220. Four handbooks scored over 80% of the maximum possible score, developed by the National Institute for Health and Clinical Excellence, Swiss Centre for International Health, Scottish Intercollegiate Guidelines Network and World Health Organization. Necessary tasks were: selecting the guideline topic, determining the guideline scope, identifying relevant existing guidelines, involving the consumers, forming guideline development group,, developing clinical questions, systematic search for evidence, selecting relevant evidence, appraising identifies research evidence, making group decision, grading available evidence, creating recommendations, final stakeholder consultation, guideline implementation strategies, updating recommendations and correcting potential errors.

Discussion

Adequate details for evidence based development of guidelines were still lacking from many handbooks. The tasks relevant to ethical issues and piloting were missing in most handbooks. The findings help decision makers in identifying the necessary tasks for guideline development, provide an updated comparative list of guideline development handbooks, and provide a checklist to assess the comprehensiveness of guideline development processes.     

Recommended reporting items for epidemic forecasting and prediction research: The EPIFORGE 2020 guidelines

BackgroundThe importance of infectious disease epidemic forecasting and prediction research is underscored by decades of communicable disease outbreaks, including COVID-19. Unlike other fields of medical research, such as clinical trials and systematic reviews, no reporting guidelines exist for reporting epidemic forecasting and prediction research despite their utility. We therefore developed the EPIFORGE checklist, a guideline for standardized reporting of epidemic forecasting research.Methods and findingsWe developed this checklist using a best-practice process for development of reporting guidelines, involving a Delphi process and broad consultation with an international panel of infectious disease modelers and model end users. The objectives of these guidelines are to improve the consistency, reproducibility, comparability, and quality of epidemic forecasting reporting. The guidelines are not designed to advise scientists on how to perform epidemic forecasting and prediction research, but rather to serve as a standard for reporting critical methodological details of such studies.ConclusionsThese guidelines have been submitted to the EQUATOR network, in addition to hosting by other dedicated webpages to facilitate feedback and journal endorsement.

Simon Pollett and co-workers describe EPIFORGE, a guideline for reporting research on epidemic forecasting.     

Designing an automated clinical decision support system to match clinical practice guidelines for opioid therapy for chronic pain

Background

Opioid prescribing for chronic pain is common and controversial, but recommended clinical practices are followed inconsistently in many clinical settings. Strategies for increasing adherence to clinical practice guideline recommendations are needed to increase effectiveness and reduce negative consequences of opioid prescribing in chronic pain patients.

Methods

Here we describe the process and outcomes of a project to operationalize the 2003 VA/DOD Clinical Practice Guideline for Opioid Therapy for Chronic Non-Cancer Pain into a computerized decision support system (DSS) to encourage good opioid prescribing practices during primary care visits. We based the DSS on the existing ATHENA-DSS. We used an iterative process of design, testing, and revision of the DSS by a diverse team including guideline authors, medical informatics experts, clinical content experts, and end-users to convert the written clinical practice guideline into a computable algorithm to generate patient-specific recommendations for care based upon existing information in the electronic medical record (EMR), and a set of clinical tools.

Results

The iterative revision process identified numerous and varied problems with the initially designed system despite diverse expert participation in the design process. The process of operationalizing the guideline identified areas in which the guideline was vague, left decisions to clinical judgment, or required clarification of detail to insure safe clinical implementation. The revisions led to workable solutions to problems, defined the limits of the DSS and its utility in clinical practice, improved integration into clinical workflow, and improved the clarity and accuracy of system recommendations and tools.

Conclusions

Use of this iterative process led to development of a multifunctional DSS that met the approval of the clinical practice guideline authors, content experts, and clinicians involved in testing. The process and experiences described provide a model for development of other DSSs that translate written guidelines into actionable, real-time clinical recommendations.

     

Intensity-time dependence dosing criterion in the EMF exposure guidelines in Russia

Major approaches of the Russian Federation in setting of exposure guidelines to electromagnetic fields (EMF) in occupational and public environments are discussed in this paper.

EMF exposure guidelines in Russia are based on the results of hygienic, clinical, physiological, epidemiological and experimental studies and are frequency-dependent. The concept of a threshold principle of occupational and environmental factors due to hazardous exposure effects has been used to set permissible exposure levels of different EMF frequency ranges. The data of experimental studies showed hazardous threshold levels of EMF effects. The main criteria of EMF hazardous exposure evaluated in the experimental study concerned both estimation of threshold levels of chronic (long-term) and acute exposure. Also, this paper contains some recent experimental study data on correlation of long-term radiofrequency and power-frequency EMF exposure effects with regard to time duration, the so-called time-dependence approach. It enables identification of the value of permissible EMF exposure levels depending on exposure duration. This approach is used in occupational exposure guideline setting and requires the introduction of “power exposition” (PE) and “maximal permissible level” (MPL). In general, EMF exposure guidelines are established with regard to possible duration of exposure per day.     

Number and type of guideline implementation tools varies by guideline,clinical condition,country of origin,and type of developer organization: content analysis of guidelines

Background

Guideline implementation tools (GI tools) can improve clinician behavior and patient outcomes. Analyses of guidelines published before 2010 found that many did not offer GI tools. Since 2010 standards, frameworks and instructions for GI tools have emerged. This study analyzed the number and types of GI tools offered by guidelines published in 2010 or later.

Methods

Content analysis and a published GI tool framework were used to categorize GI tools by condition, country, and type of organization. English-language guidelines on arthritis, asthma, colorectal cancer, depression, diabetes, heart failure, and stroke management were identified in the National Guideline Clearinghouse. Screening and data extraction were in triplicate. Findings were reported with summary statistics.

Results

Eighty-five (67.5%) of 126 eligible guidelines published between 2010 and 2017 offered one or more of a total of 464 GI tools. The mean number of GI tools per guideline was 5.5 (median 4.0, range 1 to 28) and increased over time. The majority of GI tools were for clinicians (239, 51.5%), few were for patients (113, 24.4%), and fewer still were to support implementation (66, 14.3%) or evaluation (46, 9.9%). Most clinician GI tools were guideline summaries (116, 48.5%), and most patient GI tools were condition-specific information (92, 81.4%). Government agencies (patient 23.5%, clinician 28.9%, implementation 24.1%, evaluation 23.5%) and developers in the UK (patient 18.5%, clinician 25.2%, implementation 27.2%, evaluation 29.1%) were more likely to generate guidelines that offered all four types of GI tools. Professional societies were more likely to generate guidelines that included clinician GI tools.

Conclusions

Many guidelines do not include any GI tools, or a variety of GI tools for different stakeholders that may be more likely to prompt guideline uptake (point-of-care forms or checklists for clinicians, decision-making or self-management tools for patients, implementation and evaluation tools for managers and policy-makers). While this may vary by country and type of organization, and suggests that developers could improve the range of GI tools they develop, further research is needed to identify determinants and potential solutions. Research is also needed to examine the cost-effectiveness of various types of GI tools so that developers know where to direct their efforts and scarce resources.

     

Guidelines on anticoagulant treatment in atrial fibrillation in Great Britain: variation in content and implications for treatment.

OBJECTIVE: To describe the content of guidelines on the use of anticoagulant treatment in patients with atrial fibrillation and the impact of variations in guidelines on treatment. DESIGN: Postal survey of guidelines, semistructured interview with lead developers of guidelines, and application of guidelines to patient sample. SUBJECTS: 15 lead developers of the 20 guidelines identified in the postal survey were interviewed. 100 patients over 65 with atrial fibrillation to whom the guidelines were applied. MAIN OUTCOME MEASURES: Evaluation of guidelines and the methods of dissemination, implementation, review, and evaluation; proportion of patients recommended for anticoagulant treatment by each guideline; and level of agreement between guidelines. RESULTS: There was considerable variation in whether anticoagulant treatment was recommended for subjects (range 13% to 100%, kappa = 0.12). Guidelines varied greatly in advice on treatment by age, the use of echocardiography, and the target value or range of the international normalised ratio (8 of the 20 guidelines included values unlikely to be effective). Development was unsystematic; evidence based approaches were rarely used, 9 of the 15 lead developers had developed the guidelines themselves, and the 6 guidelines developed by groups relied on informal consensus. Methods to support effective dissemination, implementation, and evaluation were limited. CONCLUSION: The widespread non-systematic production of guidelines has led to considerable variation with implications for the quality of care and clinical decision making. There is a need for a central, well funded programme of guideline development to ensure that valid guidelines are produced and disseminated.     

A Computer-Interpretable Version of the AACE,AME, ETA Medical Guidelines for Clinical Practice for the Diagnosis and Management of Thyroid Nodules

ObjectiveClinical practice guidelines (CPGs) could have a more consistent and meaningful impact on clinician behavior if they were delivered as electronic algorithms that provide patient-specific advice during patient-physician encounters. We developed a computer-interpretable algorithm for U.S. and European users for the purpose of diagnosis and management of thyroid nodules that is based on the “AACE, AME, ETA Medical Guidelines for Clinical Practice for the Diagnosis and Management of Thyroid Nodules,” a narrative, evidence-based CPG.MethodsWe initially employed the guideline-modeling language GuideLine Interchange Format, version 3, known as GLIF3, which emphasizes the organization of a care algorithm into a flowchart. The flowchart specified the sequence of tasks required to evaluate a patient with a thyroid nodule. PROforma, a second guideline-modeling language, was then employed to work with data that are not necessarily obtained in a rigid flowchart sequence. Tallis—a user-friendly web-based “enactment tool”— was then used as the “execution engine” (computer program). This tool records and displays tasks that are done and prompts users to perform the next indicated steps. The development process was iteratively performed by clinical experts and knowledge engineers.ResultsWe developed an interactive web-based electronic algorithm that is based on a narrative CPG. This algorithm can be used in a variety of regions, countries, and resource-specific settings.ConclusionElectronic guidelines provide patient-specific decision support that could standardize care and potentially improve the quality of care. The “demonstrator” electronic thyroid nodule guideline that we describe in this report is available at http://demos.deontics.com/ trace-review-app (username: reviewer; password: tnodule1). The demonstrator must be more extensively “trialed” before it is recommended for routine use. (Endocr Pract. 2014;20:352-359)