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Jackson, MS
Milwaukee, WI
Dr. Baumann is Professor of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Mississippi Medical School, and is Chair, American College of Chest Physicians, Health and Science Policy Committee. Dr. Gutterman is Professor of Medicine, Department of Medicine, Medical College of Wisconsin, is affiliated with the Veterans Affairs Medical Center, and is Vice-Chair, American College of Chest Physicians, Health and Science Policy Committee.
Correspondence to: Michael H. Baumann, MD, MS, FCCP, Professor of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Mississippi Medical School, 2500 N State St, Jackson, MS 39216-4505; e-mail: mbaumann{at}medicine.umsmed.edu
The American College of Chest Physicians (ACCP) has successfully provided high-quality clinical practice guidelines for over 10 years. Over the last 6 years, a concerted effort has been supervised by the ACCP Health and Science Policy Committee to ensure that these documents move as close as possible to an evidence-based platform. The reader is invited to visit the Health and Science Policy Committee Web site to learn more about the process of the ACCP in developing evidence-based guidelines.1 Some evidence-based guideline publication topics include lung cancer,2 pulmonary arterial hypertension,3 antithrombotic and thrombolytic therapy,4 aerosol therapy,5 atrial fibrillation after coronary arterial bypass grafting,6 and cough.7 A forthcoming evidence-based guideline will highlight occupational asthma.
All of these documents provide the best available evidence-based recommendations for the particular clinical topics at hand. However, perusal of the guidelines reveals the use of varying custom-derived grading systems on which the recommendations are based. This variability reflects the specific needs of each writing panel, but as a result the repertoire of the different grading systems can be bewildering and confusing to clinicians often wishing to compare the level of recommendations between different documents. Recognizing this problem, the ACCP financed a thorough review of our evidence grading system with the goal of developing and adopting a single grading system for all future ACCP evidence-based guidelines. In March 2005, a comprehensive review occurred at ACCP headquarters and continued off-site for several months. A new grading system was developed and was subsequently approved by the ACCP Board of Regents. This grading system arose as an adaptation of a preexisting grading methodology,8 but this adaptation is not an ACCP endorsement of that or any other existing grading system. The newly adopted ACCP system is found in this month’s issue of CHEST9 (pages 174). The consistent utilization of this grading system across all future ACCP evidence-based guidelines will provide consistency and clarity from one evidence-based guideline to another, thereby minimizing the confusion among clinicians adopting the recommendations. Furthermore, it can be "translated" to prior ACCP grading systems and to several other widely used grading systems, facilitating comparisons among guideline recommendations.
The newly adopted grading system has several advantages. First, it is less complex than our previous system. As a result it is easier to use and understand by the practicing clinician. The simplicity results in part from a more comprehensive view of what constitutes evidence. In the past, there was an arbitrary threshold that separated "quality evidence" from "expert opinion," with the former derived from randomized controlled trials and the latter from small observational studies or even case reports. In the new grading system, all relevant published data are considered to be evidence. As a result, the definition of weak evidence has been extended. Another advantage of the new system is the emphasis on benefits vs risks and the burdens imposed by recommendations. This allows a greater focus when crafting recommendations on patient-centered outcomes, and the preferences and values of patients.
In addition to adopting a uniform grading system for evidence-based guidelines, the ACCP also began a systematic evaluation of how recommendations might impact resource utilization. To date, no evidence-based guideline, regardless of its sponsoring organization, has provided a consistent and transparent approach to resource/cost considerations in its recommendations. In part, this is due to the widespread differences in resource utilization internationally, the rapidly changing or variable costs from region to region, and the complexity of the resource issue impacting patients, caregivers, insurance providers, and others. It is important to note that resource/cost considerations involve not simply assessing the easily recognized immediate dollars consumed, but all surrounding and downstream resource effects of implementing a particular evidence-based guideline recommendation. One ideally must consider all consumed resources.
Recognizing the importance of resource considerations in ACCP evidence-based guidelines, the ACCP financed an in-depth evaluation of this topic, which also occurred in March 2005 concurrent with the convening evidence-based guideline grading system task force described above. The resulting document was critiqued and edited by all participants for several months, with the final outcome of the working group also found in this issue of CHEST10 (pages 182). This document represents what we think is the first published document providing a rational framework for considering resource consumption during the creation of an evidence-based guideline. Although evidence-based guideline grading systems have been evolving for over 10 years, the incorporation of resource utilization into evidence-based recommendations is very much in its infancy. Notably, the newly adopted ACCP evidence grading system considers resource consumption in developing evidence-based recommendations.
The resource document provides a framework for those considerations with nine specific recommendations. A central theme within these nine recommendations is that only a limited number of the recommendations within any evidence-based guideline can be selected for resource assessment. This has primarily evolved from the costly nature of incorporating resource considerations into evidence-based guidelines, in terms of both dollars and expertise. A framework for selecting evidence-based guideline recommendations for resource consideration is provided. Those selected should be ones in which the incorporation of resource considerations will most likely influence the direction or strength of a recommendation.
The resulting evidence-grading and resource-utilization documents are not stand-alone products, but are meant to be used in concert. As experience is gained in using these documents, refinements and improvements will occur, especially with resource utilization, given the current nascent stage of development. However, the ultimate goal is that when used together, these documents will generate higher quality evidence-based guidelines with more sophisticated evidence grading producing higher quality evidence-based recommendations that thoughtfully consider the impact of resource consumption. Such a unified approach will lead to a more comprehensive consideration of patient values and preferences, and, ultimately, to a more focused approach to patient-centered, evidence-based recommendations. In the end, this guideline development approach aligns with the mission of the ACCP of providing tools enabling the practicing clinician to provide the best possible patient-centered care.
References
This article has been cited by other articles:
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  M. H. Baumann, S. Z. Lewis, and D. Gutterman ACCP Evidence-Based Guideline Development: A Successful and Transparent Approach Addressing Conflict of Interest, Funding, and Patient-Centered Recommendations Chest, September 1, 2007; 132(3): 1015 - 1024. [Abstract] [Full Text] [PDF]
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