Reassessment of Clinical Practice Guidelines

ArticleinJAMA The Journal of the American Medical Association 301(8):868-9 · March 2009with20 Reads
DOI: 10.1001/jama.2009.225 · Source: PubMed
In 1990, the Institute of Medicine proposed guideline development to reduce inappropriate health care variation by assisting patient and practitioner decisions.1 Unfortunately, too many current guidelines have become marketing and opinion-based pieces, delivering directive rather than assistive statements.Current use of the term guideline has strayed far from the original intent of the Institute of Medicine. Most current articles called “guidelines” are actually expert consensus reports. It is not surprising, then, that the article by Tricoci et al2 in this issue of JAMA demonstrates that revisions of the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines have shifted to more class II recommendations (conflicting evidence and/or divergence of opinion about the usefulness/efficacy of a procedure or treatment) and that 48% of the time, these recommendations are based on the lowest level of evidence (level C: expert opinion, case studies, or standards of care). This trend is especially disconcerting given the quantity of cardiovascular scientific literature published during the last decade.
    • "When authors of systematic reviews hold financial conflicts of interest, they are more likely to interpret data as evidence supporting an intervention [9, 36, 37]. Contributors to clinical practice guidelines are more likely to recommend the intervention in clinical practice if they hold a conflict of interest [10, 38, 39]. Both disclosed and undisclosed conflicts of interest can have a negative impact on clinical evidence, public opinion, and clinical decision-making [40]. "
    [Show abstract] [Hide abstract] ABSTRACT: Conflicts of interest held by researchers remain a focus of attention in clinical research. Biases related to these relationships have the potential to directly impact the quality of healthcare by influencing decision-making, yet conflicts of interest remain under-reported, inconsistently described, and difficult to access. Initiatives aimed at improving the disclosure of researcher conflicts of interest are still in their infancy but represent a vital reform that must be addressed before potential biases associated with conflicts of interest can be mitigated, and trust in the impartiality of clinical evidence restored. In this review, we examine the prevalence of conflicts of interest, evidence of the effects that disclosed and undisclosed conflicts of interest have had on the reporting of clinical evidence, and the emerging approaches for improving the completeness and consistency of disclosures. Through this review of emerging technologies, we recognize a growing interest in publicly-accessible registries for researcher conflicts of interest, and propose five desiderata aimed at maximizing the value of such registries: mandates for ensuring that researchers keep their records up to date; transparent records that are made available to the public; interoperability to allow researchers, bibliographic databases, and institutions to interact with the registry; a consistent taxonomy for describing different classes of conflicts of interest, and the ability to automatically generate conflicts of interest statements for use in published articles.
    Article · Dec 2016
    • "Common flaws include poor literature review methodology, limited involvement of stakeholders and unclear editorial independence (Alonso-Coello et al., 2010). Therefore, valid concerns exist about the potentially negative impact of biased guidelines on the care and health outcomes of patients (DelgadoNoguera et al., 2009; Shaneyfelt and Centor, 2009; Tricoci et al., 2009; Alonso-Coello et al., 2010). Guidelines of poor methodological quality may lead clinicians to consider interventions that are ineffective, costly, or harmful. "
    [Show abstract] [Hide abstract] ABSTRACT: We conducted a systematic review of guidelines on the management of low back pain (LBP) to assess their methodological quality and guide care. We synthesized guidelines on the management of LBP published from 2005 to 2014 following best evidence synthesis principles. We searched MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane, DARE, National Health Services Economic Evaluation Database, Health Technology Assessment Database, Index to Chiropractic Literature and grey literature. Independent reviewers critically appraised eligible guidelines using AGREE II criteria. We screened 2504 citations; 13 guidelines were eligible for critical appraisal, and 10 had a low risk of bias. According to high-quality guidelines: (1) all patients with acute or chronic LBP should receive education, reassurance and instruction on self-management options; (2) patients with acute LBP should be encouraged to return to activity and may benefit from paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), or spinal manipulation; (3) the management of chronic LBP may include exercise, paracetamol or NSAIDs, manual therapy, acupuncture, and multimodal rehabilitation (combined physical and psychological treatment); and (4) patients with lumbar disc herniation with radiculopathy may benefit from spinal manipulation. Ten guidelines were of high methodological quality, but updating and some methodological improvements are needed. Overall, most guidelines target nonspecific LBP and recommend education, staying active/exercise, manual therapy, and paracetamol or NSAIDs as first-line treatments. The recommendation to use paracetamol for acute LBP is challenged by recent evidence and needs to be revisited. Most high-quality guidelines recommend education, staying active/exercise, manual therapy and paracetamol/NSAIDs as first-line treatments for LBP. Recommendation of paracetamol for acute LBP is challenged by recent evidence and needs updating.
    Full-text · Article · Oct 2016
    • "In the biomedical domain of the CREST data, judgments of importance play a vital role. At the same time, guideline authoring is a subjective process (Shaneyfelt and Centor, 2009 ); clinical practitioners may apply their own experience when interpreting evidence (Shrier et al., 2008). This can lead to inconsistency in the choice of strength Table 5 bels, and arguably the linguistic choices made in association with the labels. "
    [Show abstract] [Hide abstract] ABSTRACT: In this paper we present the Corpus of REcommendation STrength (CREST), a collection of HTML-formatted clinical guidelines annotated with the location of recommendations. Recommendations are labelled with an author-provided indicator of their strength of importance. As data was drawn from many disparate authors, we define a unified scheme of importance labels, and provide a mapping for each guideline. We demonstrate the utility of the corpus and its annotations in some initial measurements investigating the type of language constructions associated with strong and weak recommendations, and experiments into promising features for recommendation classification, both with respect to strong and weak labels, and to all labels of the unified scheme. An error analysis indicates that, while there is a strong relationship between lexical choices and strength labels, there can be substantial variance in the choices made by different authors.
    Full-text · Conference Paper · May 2016 · European journal of pain (London, England)
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