American Psychiatric Association Practice Guideline Development Challenges and Ideas for Standards.
-
Upload
marjorie-bailey -
Category
Documents
-
view
212 -
download
0
Transcript of American Psychiatric Association Practice Guideline Development Challenges and Ideas for Standards.
American Psychiatric Association Practice
Guideline Development
Challenges and Ideas for Standards
Laura J. Fochtmann, M.D.
Professor, Departments of Psychiatry and Behavioral Science and Pharmacological Sciences, Stony Brook University, Stony Brook, New York
Medical Editor, Practice Guidelines, American Psychiatric Association
No disclosures
APA Practice Guidelines Acute Stress Disorder and PTSD (2004) Alzheimer’s Disease and Other Dementias (1997, 2007) Bipolar Disorder (1994, 2002, in development) Borderline Personality Disorder (2001) Delirium (1999) Eating Disorders (1993, 2000, 2006) HIV/AIDS (2000) Major Depressive Disorder (1993, 2000, in development) Obsessive-Compulsive Disorder (2007) Panic Disorder (1998, 2009) Psychiatric Evaluation (1995, 2006) Schizophrenia (1997, 2004) Substance Use Disorders (1995, 2006) Suicidal Behaviors (2003)
Print publications
Education and Certification
Online
CME
Examinations
Self-Evaluation Tools
Quality indicators
National Guideline Clearinghouse
Concise formats
APA Development Process Comprehensive literature search Evidence tables Expert work group Zero industry funding Conflict of interest policy for all
participants Broad, iterative review of drafts Approval by the APA Assembly and Board
of Trustees
General Development Challenges
Increasing demand for new guidelines Need for constant updating of prior
guidelines Volume of new evidence Time- and resource-intensive
development process, especially for rigorous systematic literature reviews
Composition of volunteer work groups Approval through APA governance
Funding Challenges
Need to maintain independence from industry funding
Desire for broad dissemination over publication profits
Limited funds available for staff and other support
Limited public grant opportunities to support development?
Challenges Related to Available Evidence Base RCTs may be unavailable for important
clinical questions or for off-patent treatments.
RCTs can be biased. Studies often have limited generalizability. Available data rarely lend themselves to
medical decision analysis. Relatively small samples do not permit
assessment of confounds or special factors that may alter treatment.
Challenges in Determining Strength of Recommendation Evidence is rarely straightforward to
translate into practice recommendations.
Best methods for achieving consensus recommendations have not been defined (e.g., methodology, consensus panel composition, strength ratings).
Consensus of a small expert panel may not represent broader clinical opinion.
Challenges in Increasing Usability and Adherence
Need for broadly stated recommendations to Reflect complexity of real world patients Give clinicians flexibility in individualizing care
without creating medicolegal or utilization review difficulties
Reflect ambiguous or limited evidence Need for simplification and clarity to
Enhance use of guidelines at the point of care Make them applicable to specific clinical
situations Translate them into quality measures and
machine-readable algorithms
Ideas for Standards for Guideline Development
Specify clear, distinct criteria for strength of evidence and ratings of recommendation strength
Be explicit about evidence used in making a recommendation, method by which the recommendation was reached, and evidence gaps.
Develop standardized approaches to considering (and making explicit or minimizing) effects of bias.
Develop standardized methods for achieving consensus. Allow for flexibility in composition of guideline panels. Choose clinically meaningful EHR and quality measures. Recognize that guideline-related needs of clinicians and
patients may vary across specialties and settings.
Ideas for Improving Guideline Concordance and Currency
Standardize the reporting of clinical trial data. Create a publicly funded database of the clinical
trial evidence tables (e.g., within MEDLINE). Create a mechanism for developers to share
information about guidelines that are in process. Continue expansion of AHRQ funding of
systematic reviews. Consider alternative models for funding of
guideline development per se Avoid standards or accreditation that would
place additional costs or burdens on guideline development by professional societies.
APA Steering Committee on Practice Guidelines
Darrel A. Regier, M.D., Director, Division of ResearchRobert M. Plovnick, M.D., M.S., Director, Dept of Quality
ImprovementRobert Kunkle, M.A., Director, Practice Guidelines Project
Joel Yager, M.D., ChairJames E. Nininger, M.D., Vice-Chair
APA Staff
Daniel J. Anzia, M.D. Sherwyn M. Woods, M.D., Ph.D.Thomas J. Craig, M.D. John S. McIntyre, M.D., ConsultantMolly T. Finnerty, M.D. Kristen Ochoa, M.D., FellowFrancis G. Lu, M.D. Jeremy Wilkinson, M.D., FellowPaul Summergrad, M.D. Sheila Hafter Gray, M.D., LiaisonMichael J. Vergare, M.D.