Question

What are guidelines?

Answer

a. Recommendations for the performance or exclusion of specific procedures or services
derived through a rigorous methodological approach that includes the following:

1. Determination of appropriate criteria, such as effectiveness, efficacy, population benefit,
or patient satisfaction; and
2. Literature review to determine the strength of the evidence (based in part on study design) in relation to these criteria.

b. Guidelines are frequently displayed in the form of an algorithm. An algorithm is a set of rules for solving a problem in a finite number of steps. Typically, a clinical algorithm diagrams a guideline into a step-by-step decision-tree.

Question

What are the main characteristics of a high-quality Clinical Practice Guideline?

Answer

"Characteristics of a good guideline include:

• Validity - Correctly interpreting available evidence, so that when followed, valid guidelines lead to improvements in health.
• Reproducibility - Given the same evidence another guideline group produces similar recommendations.
• Reliability - Given the same clinical circumstances another health professional applies them similarly.
• Clinical Applicability - Target population is defined in accordance with scientific evidence.
• Clinical Flexibility - Guidelines identify exceptions and indicate how patient preferences are to be incorporated in decision making.
• Cost effectiveness - Guidelines lead to improvements in health at acceptable costs.
• Clarity - Guidelines use precise definitions, unambiguous language, and user-friendly formats.
• Multidisciplinary Process - All key disciplines and interests (including patients) contribute to guideline development.
• Scheduled Review - Guidelines state when and how they are to be reviewed.
• Documentation - Guidelines record participants, assumptions, and methods; and link recommendations to available evidence.

Reference "Implementing Clinical Practice Guidelines" authored by Carmi Margolis, MD and Shan Cretin, PhD, page 103, "Table 6-1."

Question

What is a clinical algorithm?

Answer

Typically, a clinical algorithm diagrams a guideline into a step-by-step decision-tree.

Question

What is the reason for putting the guideline into an algorithm?

Answer

The algorithmic format allows clinicians to follow a linear approach to critical clinical information needed at the major decision points in the disease management process and stepwise evaluation and management strategies that include the following:

• Ordered sequence of steps of care
• Required observations to be made
• Decisions to be considered
• Actions to be taken

It is recognized, however, that clinical practice often requires a nonlinear approach and must always reflect the unique clinical issues in an individual patient-clinician situation.

Question

Do clinical algorithms limit clinical thinking?

Answer

On the contrary, it may be argued that using a specific approach to solving a clinical problem is essential to proper clinical decision making and may increase the clinician's ability to recognize unusual problems. Reference "Implementing Clinical Practice Guidelines" authored by authored by Carmi Margolis, MD and Shan Cretin, PhD, page 210, #9

Question

What are Clinical Pathways?

Answer

Clinical Pathways are clinical management plans that organize, sequence, and specify timing for the major patient care activities and interventions of the entire interdisciplinary team for a particular diagnosis or procedure. Clinical pathways define key processes and events in the day-to-day management of care. They differ from guidelines, as defined by VHA, by focusing on the quality and efficiency of care after decisions have already been made to perform the procedure or service. They are almost always locally developed based upon a broader guideline and may be included as a part of the clinical record. Variance from the pathway along with causes of variance should be documented.decision-tree.

Question

Where did the guidelines come from?

Answer

Clinical practice guidelines initially evolved in response to studies demonstrating significant variations in risk-adjusted practice patterns and costs. Researchers hypothesized that establishing criteria for the appropriate use of procedures and services might decrease inappropriate utilization and improve patient outcomes. Professional societies, health care policy groups, non-profit disease-oriented organizations, and government-appointed panels were among those who responded by publishing position papers, efficacy reports, practice policies, and other forms of advice to practitioners. While definitive evidence is not yet available, these clinical practice guidelines appear to be having an appreciable impact on medical care.

Question

How can I be sure that a clinical guideline is based on scientific evidence?

Answer

The literature search is followed by critical analysis of the literature, primarily by the clinical experts. To promote an evidence-type approach, the quality of evidence is rated using a hierarchical rating scheme. The value of a hierarchical rating scheme is that it provides a systematic means for evaluating the scientific basis for health care service (3). The rating scheme used for the COPD guideline is based on a system used by the Agency for Health Care Policy and Research. Decision points in the algorithm are annotated, and the primary source documents for the annotation are graded. The grading scheme used for the COPD guideline is:

STRENGTH OF RECOMMENDATION GRADING (4)

Grade	Strength of Recommendation
I	Usually indicated, always acceptable, and considered useful and effective.
Iia	Acceptable, of uncertain effectiveness, and may be controversial. Weight of evidence in favor of usefulness/effectiveness.
IIb	Acceptable, of uncertain effectiveness, and may be controversial. Not well established by evidence, can be helpful and probably not harmful.

LEVEL OF EVIDENCE GRADING

Level of Evidence Grading = A	Level of Evidence Grading = B	Level of Evidence Grading = C
Primary Evidence	Randomized clinical trials	Well-designed clinical studies	Panel consensus
Secondary Evidence	Other clinical studies	Clinical studies related to topic but not in this clinical population	Clinical studies related to topic but not in this clinical population

Other guidelines may use different systems for grading evidence such as those used by the U.S. Preventive Services Task Force. Each guideline will describe the strategy that was applied.