Developing good practice guidelines

[StATS]: Developing good practice guidelines (February 18, 2005)

A physician here, Lloyd Olson, who has been aggressively promoting Evidence Based Medicine suggested the following interesting article on practice guidelines.<U+FFFD>

• Are guidelines following guidelines? The methodological quality of clinical practice guidelines in the peer-reviewed medical literature. Shaneyfelt TM, Mayo-Smith MF, Rothwangl J. Jama 1999: 281(20); 1900-5. [Medline]

According to the article, practice guidelines are

“systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances."

The article evaluated 279 guidelines published between 1985 and 1997 on a list of 25 items:

1. Purpose of the guideline is specified.
2. Rationale and importance of the guideline are explained.
3. The participants in the guideline development process and their area of expertise are specified.
4. Targeted health problem or technology is clearly defined.
5. Targeted patient population is specified.
6. Intended audience or users of the guideline are specified.
7. The principal preventive, diagnostic, or therapeutic options available to clinicians and patients are specified.
8. The health outcomes are specified.
9. The method by which the guideline underwent external review is specified.
10. An expiration date or date of scheduled review is specified.
11. Method of identifying scientific evidence is specified.
12. Time period from which evidence is reviewed is specified.
13. The evidence used is identified by citation and referenced.
14. Method of data extraction is specified.
15. Method fro grading or classifying the scientific evidence is specified.
16. Formal methods of combining evidence or expert opinion are used and described.
17. Benefits and harms of specific health practices are specified.
18. Benefits and harms are quantified.
19. The effect on health care costs from specific health practices is specified.
20. Costs are quantified.
21. The role of value judgments used by the guideline developers in making recommendation is discussed.
22. The role of patient preferences is discussed.
23. Recommendations are specific and apply to the stated goals of the guideline.
24. Recomendations are graded according to the strength of the evidence.
25. Flexibility in the recommendations is specified.

Although there are some improvement over time, the overall degree of compliance with these items was still only about half in 1997.

A good annotated bibliography with more details about developing guidelines is on the web at

• http://www.guideline.gov/ab/default.aspx

Here are some additional articles about the development and evaluation of guidelines in my files:

• Quality and methods of developing practice guidelines. Cruse H, Winiarek M, Marshburn J, Clark O, Djulbegovic B. BMC Health Serv Res 2002: 2(1); 1. [Medline] [Abstract] [Full text] [PDF]
• Rating the quality of evidence for clinical practice guidelines. Hadorn DC, Baker D, Hodges JS, Hicks N. J Clin Epidemiol 1996: 49(7); 749-54.
• Users' guides to the medical literature: XVII. How to use guidelines and recommendations about screening. Evidence-Based Medicine Working Group. Barratt A, Irwig L, Glasziou P, Cumming RG, Raffle A, Hicks N, Gray JA, Guyatt GH. Jama 1999: 281(21); 2029-34. [Medline]
• Users' guides to the medical literature. VIII. How to use clinical practice guidelines. A. Are the recommendations valid? Hayward R, Wilson M, Tunis S, Bass E, Guyatt G. JAMA 1995: 274(7); 570-4.
• Users' guides to the medical literature. VIII. How to use clinical practice guidelines. B. What are the recommendations, and will they help you in caring for your patients? Hayward R, Tunis S, Wilson M, Bass E, Guyatt G. JAMA 1995: 274(20); 1630-2.
• Standardized Reporting of Clinical Practice Guidelines: A Proposal from the Conference on Guideline Standardization. Shiffman RN, Shekelle P, Overhage JM, Slutsky J, Grimshaw J, Deshpande AM. Ann Intern Med 2003: 139(6); 493 -498. [Abstract] [Full text] [PDF]
• Use of systematic reviews in clinical practice guidelines: case study of smoking cessation. Silagy CA, Stead LF, Lancaster T. Bmj 2001: 323(7317); 833-6.
• A new system for grading recommendations in evidence based guidelines. Harbour R, Miller J. British Medical Journal 2001: 323(7308); 334-6. [Medline] [Full text] [PDF]
• Guidelines for clinical guidelines [editorial]. Jackson R, Feder G. British Medical Journal 1998: 317(7156); 427-8.

You can find an earlier version of this page on my website.