CLINICAL PRACTICE GUIDELINESSushil Kumar Sompur MD

CLINICAL PRACTICE GUIDELINES Systematically developed statements to

assist practitioner decisions about appropriate health care for specific clinical circumstances

Recent uptick in interest in developing guidelines due to concerns about variability in clinical practice, cost, quality and legal liability

Guidelines also differ considerably in comprehensiveness, format, frequency of review and ease of use

ROLE OF GUIDELINES IN EVIDENCE BASED PRACTICE CPGs are viewed as distinct from EBP

Not all CPGs are derived from a systematic review of the medical literature

All guidelines involve some degree of judgment and bias in their development, extent of which is often unstated

CPGs are a “top-down” approach to changing clinician behavior leading to clinician resistance v/s EBM which is a “bottom-up” approach which is based on the clinicians ability to search and appraise the available literature

However high quality Evidence Based Guidelines that includes a systematic review of literature may provide useful guidance

SOURCES OF GUIDELINES AHRQ’s National Guideline Clearinghouse –

http://www.guideline.gov/browse/browsecondition.aspx

American Psychiatric Association - http://www.psychiatryonline.com.ezproxy.undmedlibrary.org/pracGuide/pracGuideHome.aspx

Expert Opinion - http://www.psychguides.com/

Texas Medication Algorithms Project (TMAP) - http://www.dshs.state.tx.us/mhprograms/disclaimer.shtm

Other organizations – Canadian Psychiatric Association, New Zealand Guidelines Groups, Scottish Intercollegiate Guideline Network and UK National Health Service

DEVELOPING EVIDENCE BASED PRACTICE GUIDELINES

Steps in developing evidence-based practice guidelines1 Identify and refine the topic of the guideline2 Convene an appropriate group

•Typically 6-20 members•Requires both clinical and statistical expertise•Should be multidisciplinary

3 Gather and Assess the Evidence•Systematic Review of Literature•Hierarchy of evidence

4 Translate the evidence into recommendations – Some degree of clinical judgment is always needed •To weigh conflicting information •When there is little evidence

5 Use outside reviewers to review the recommendations•Should include users as well as Experts•Assess for validity and practicality

6 Update the guideline periodically

Critical Appraisal of Guidelines

Is the Guideline Valid ?

• Did the developers carry out a systematic review of the literature ?• Were all relevant treatment options and outcomes considered ?• Did the developers specify and make explicit the values associated with various outcomes ?• Did the developers indicate the level of evidence (and sources) upon which each recommendation was based?Is the Guideline applicable to my practice ?

• Is the burden of illness too low to warrant implementation ?• Are the beliefs of my patients incompatible with the guidelines ?• Are the costs and other barriers of implementation too high ?

THANKS !