Medical guideline

Short description: Document with the aim of guiding decisions and criteria in healthcare

Not to be confused with Clinical pathway.

Plates vi & vii of the Edwin Smith Papyrus (around the 17th century BC), among the earliest medical guidelines

A medical guideline (also called a clinical guideline, standard treatment guideline, or clinical practice guideline) is a document with the aim of guiding decisions and criteria regarding diagnosis, management, and treatment in specific areas of healthcare. Such documents have been in use for thousands of years during the entire history of medicine. However, in contrast to previous approaches, which were often based on tradition or authority, modern medical guidelines are based on an examination of current evidence within the paradigm of evidence-based medicine.[1][2][3] They usually include summarized consensus statements on best practice in healthcare. A healthcare provider is obliged to know the medical guidelines of their profession, and has to decide whether to follow the recommendations of a guideline for an individual treatment.[4]

## Contents

* 1 Background
* 2 Publication
* 3 Compliance
* 4 Problems
* 4.1 Quality
* 4.2 Exclusion of non-expert stakeholders
* 4.3 Timeliness
* 5 Examples
* 6 See also
* 7 References
* 8 External links

## Background

Modern clinical guidelines identify, summarize and evaluate the highest quality evidence and most current data about prevention, diagnosis, prognosis, therapy including dosage of medications, risk/benefit and cost-effectiveness. Then they define the most important questions related to clinical practice and identify all possible decision options and their outcomes. Some guidelines contain decision or computation algorithms to be followed. Thus, they integrate the identified decision points and respective courses of action with the clinical judgement and experience of practitioners. Many guidelines place the treatment alternatives into classes to help providers in deciding which treatment to use.

Additional objectives of clinical guidelines are to standardize medical care, to raise quality of care, to reduce several kinds of risk (to the patient, to the healthcare provider, to medical insurers and health plans) and to achieve the best balance between cost and medical parameters such as effectiveness, specificity, sensitivity, resoluteness, etc. It has been demonstrated repeatedly that the use of guidelines by healthcare providers such as hospitals is an effective way of achieving the objectives listed above, although they are not the only ones.

## Publication

Guidelines are usually produced at national or international levels by medical associations or governmental bodies, such as the United States Agency for Healthcare Research and Quality. Local healthcare providers may produce their own set of guidelines or adapt them from existing top-level guidelines. Healthcare payers such as insurers practicing utilization management also publish guidelines.[5]

Special computer software packages known as guideline execution engines have been developed to facilitate the use of medical guidelines in concert with an electronic medical record system. The Guideline Interchange Format (GLIF) is a computer representation format for clinical guidelines that can be used with such engines.[6]

The US and other countries maintain medical guideline clearinghouses. In the US, the National Guideline Clearinghouse maintains a catalog of high-quality guidelines published by various health and medical associations. In the United Kingdom, clinical practice guidelines are published primarily by the National Institute for Health and Care Excellence (NICE). In The Netherlands, two bodies—the Institute for Healthcare Improvement (CBO) and College of General Practitioners (NHG)—have published specialist and primary care guidelines, respectively. In Germany, the German Agency for Quality in Medicine (ÄZQ) coordinates a national program for disease management guidelines. All these organisations are now members of the Guidelines International Network (G-I-N), an international network of organisations and individuals involved in clinical practice guidelines.

## Compliance

The New York Times reported in 2004 that some simple clinical practice guidelines are not routinely followed to the extent they might be.[7] It has been found that providing a nurse or other medical assistant with a checklist of recommended procedures can result in the attending physician being reminded in a timely manner regarding procedures that might have been overlooked.

Checklists have been used in medical practice to attempt to ensure that clinical practice guidelines are followed. An example is the Surgical Safety Checklist developed for the World Health Organization by Atul Gawande.[8] According to a meta-analysis after introduction of the checklist mortality dropped by 23% and all complications by 40%, but further high-quality studies are required to make the meta-analysis more robust.[9] In the UK, a study on the implementation of a checklist for provision of medical care to elderly patients admitting to hospital found that the checklist highlighted limitations with frailty assessment in acute care and motivated teams to review routine practices, but that work is needed to understand whether and how checklists can be embedded in complex multidisciplinary care.[10]

## Problems

### Quality

Guidelines may have both methodological problems and conflict of interest.[11] As such, the quality of guidelines may vary substantially,[12] especially for guidelines that are published online and have not had to follow methodological reporting standards often required by reputable clearinghouses.[13]

Guidelines may make recommendations that are stronger than the supporting evidence.[14]

### Exclusion of non-expert stakeholders

Patients and caregivers are frequently excluded from clinical guidelines development, in part because there is a lack of guidance for how to include them in the process.[15]

### Timeliness

Guidelines may lose their clinical relevance as they age and newer research emerges.[16] Even 20% of strong recommendations, especially when based on opinion rather than trials, from practice guidelines may be retracted.[17]

In response to many of the problems with traditional guidelines, the BMJ created a new series of trustworthy guidelines focused on the most pressing medical issues called BMJ Rapid Recommendations.[18]

## Examples

* The American Heart Association Guidelines for the Prevention of Infective Endocarditis[19]
* BMJ Rapid Recommendations[18] guideline on transcatheter aortic valve implantation versus surgical aortic valve replacement for aortic stenosis[20]
* Maudsley Prescribing Guidelines
* WHO SMART guidelines

## See also

* Clinical formulation
* Clinical prediction rule
* Clinical trial protocol
* Medical algorithm
* The Medical Letter on Drugs and Therapeutics

## References

1. ↑ "Towards evidence-based clinical practice: an international survey of 18 clinical guideline programs". Int J Qual Health Care 15 (1): 31–45. 2003. doi:10.1093/intqhc/15.1.31. PMID 12630799.
2. ↑ AGREE Collaboration (2003). "Development and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: the AGREE project". Qual Saf Health Care 12 (1): 18–23. doi:10.1136/qhc.12.1.18. PMID 12571340.
3. ↑ Institute of Medicine (edt.) Clinical practice guidelines we can trust. Washington DC, 2011
4. ↑ Council of Europe. Developing a methodology for drawing up guidelines on best medical practice. Recommendation Rec(2001)13 and explanatory memorandum. Strasbourg: Council of Europe Publishing, 2002.
5. ↑ Moses, Richard E.; Feld, Andrew D. (2008-01-01). "Legal risks of clinical practice guidelines". The American Journal of Gastroenterology 103 (1): 7–11. doi:10.1111/j.1572-0241.2007.01399.x. ISSN 0002-9270. PMID 18184116.
6. ↑ GLIF website
7. ↑ Gina Kolata "Program Coaxes Hospitals to See Treatments Under Their Noses". The New York Times December 25, 2004.
8. ↑ Haynes, Alex B.; Weiser, Thomas G.; Berry, William R.; Lipsitz, Stuart R.; Breizat, Abdel-Hadi S.; Dellinger, E. Patchen; Herbosa, Teodoro; Joseph, Sudhir et al. (29 January 2009). "A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population". New England Journal of Medicine 360 (5): 491–499. doi:10.1056/NEJMsa0810119. PMID 19144931. https://dash.harvard.edu/bitstream/1/38846186/1/Gawande_Surgical Safety Checklist to Reduce Morbidity vor.pdf.
9. ↑ Bergs, J.; Hellings, J.; Cleemput, I.; Zurel, Ö.; De Troyer, V.; Van Hiel, M.; Demeere, J.-L.; Claeys, D. et al. (February 2014). "Systematic review and meta-analysis of the effect of the World Health Organization surgical safety checklist on postoperative complications". British Journal of Surgery 101 (3): 150–158. doi:10.1002/bjs.9381. PMID 24469615.
10. ↑ Papoutsi, Chrysanthi; Poots, Alan; Clements, Jake; Wyrko, Zoe; Offord, Natalie; Reed, Julie E (5 January 2018). "Improving patient safety for older people in acute admissions: implementation of the Frailsafe checklist in 12 hospitals across the UK". Age and Ageing 47 (2): 311–317. doi:10.1093/ageing/afx194. PMID 29315375.
11. ↑ Reames BN; Krell RW; Ponto SN; Wong SL (2013). "Critical evaluation of oncology clinical practice guidelines". J Clin Oncol 31 (20): 2563–8. doi:10.1200/JCO.2012.46.8371. PMID 23752105.
12. ↑ Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, Fervers B, Graham ID, Grimshaw J, Hanna SE, Littlejohns P, Makarski J, Zitzelsberger L, for the AGREE Next Steps Consortium. AGREE II: Advancing guideline development, reporting and evaluation in healthcare. Canadian Medical Association Journal 2010;182:E839-842 (2017 update).
13. ↑ "An Evaluation of Web-Based Clinical Practice Guidelines for Managing Problems Associated with Cannabis Use". J Med Internet Res 14 (6): e169. 2012. doi:10.2196/jmir.2319. PMID 23249447.
14. ↑ Brito JP; Domecq JP; Murad MH; Guyatt GH et al. (2013). "The Endocrine Society guidelines: when the confidence cart goes before the evidence horse". J Clin Endocrinol Metab 98 (8): 3246–52. doi:10.1210/jc.2013-1814. PMID 23783104.
15. ↑ Khodyakov, Dmitry; Kinnett, Kathi; Grant, Sean; Lucas, Ann; Martin, Ann; Denger, Brian; Peay, Holly; Coulter, Ian et al. (2017-04-28). "Engaging Patients and Caregivers Managing Rare Diseases to Improve the Methods of Clinical Guideline Development: A Research Protocol" (in en). JMIR Research Protocols 6 (4): e57. doi:10.2196/resprot.6902. ISSN 1929-0748. PMID 28455279.
16. ↑ Shekelle PG et al. (2001). "Validity of the Agency for Healthcare Research and Quality clinical practice guidelines: how quickly do guidelines become outdated?". JAMA 286 (12): 1461–7. doi:10.1001/jama.286.12.1461. PMID 11572738.
17. ↑ Neuman MD; Goldstein JN; Cirullo MA; Schwartz JS (2014). "Durability of class I American College of Cardiology/American Heart Association clinical practice guideline recommendations". JAMA 311 (20): 2092–100. doi:10.1001/jama.2014.4949. PMID 24867012.
18. ↑ 18.0 18.1 Siemieniuk, Reed A; Agoritsas, Thomas; Macdonald, Helen; Guyatt, Gordon H; Brandt, Linn; Vandvik, Per O (28 September 2016). "Introduction to BMJ Rapid Recommendations". BMJ 354. doi:10.1136/bmj.i5191. ISSN 1756-1833. PMID 27680768.
19. ↑ Wilson W et al. (October 2007). "Prevention of infective endocarditis: guidelines from the American Heart Association". Circulation 116 (15): 1736–54. doi:10.1161/CIRCULATIONAHA.106.183095. PMID 17446442. http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=17446442.
20. ↑ "Transcatheter or surgical aortic valve replacement for patients with severe, symptomatic, aortic stenosis at low to intermediate surgical risk: a clinical practice guideline". BMJ 354. 2016. doi:10.1136/bmj.i5085. PMID 27680583. http://www.bmj.com/content/354/bmj.i5085.long.

## External links

* British Columbia Medical Guidelines – In Canada, British Columbia's guidelines and protocols are developed under the direction of the Guidelines and Protocols Advisory Committee (GPAC), jointly sponsored by the B.C. Medical Association and the B.C. Ministry of Health Services.
* The Cochrane Collaboration – An international, independent, not-for-profit organisation of over 27,000 contributors from more than 100 countries, dedicated to making up-to-date, accurate information about the effects of health care readily available worldwide.
* GuiaSalud. Clinical Practice Guidelines for the National Health System (Spain) – Contains clinical practice guidelines developed in Spain translated into English.
* Guideline Elements Model – The Guideline Elements Model (GEM) is an ASTM standard for the representation of practice guidelines in XML format.
* Guideline Interchange Format – The Guideline Interchange Format (GLIF) is a specification for structured representation of guidelines.
* Guidelines International Network – Contains the largest online guideline library.
* Hospital Quality Alliance – A project of the Hospital Quality Initiative (HQI) of the Centers for Medicare and Medicaid Services (USA).
* National Guideline Clearinghouse (NGC) – A public resource for evidence-based clinical practice guidelines. NGC is an initiative of the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services.
* Scottish Intercollegiate Guidelines Network (SIGN) – Contains 113 evidence-based clinical guidelines – published, in development, or under review.
* German guidelines (AWMF) – A collection of current German health care-related professional associations' guidelines.

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