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Rockville, MD
Dr. Clancy is Director, Agency for Healthcare Research and Quality. Ms. Slutsky is Director, Center for Outcomes and Research, Agency for Healthcare Research and Quality.
Correspondence to: Jean R. Slutsky, PA, MSPH, Director, Center for Outcomes and Evidence, Agency for Healthcare Research and Quality, John M. Eisenberg Building, 540 Gaither Rd, Rockville, MD 20850; e-mail: jean.slutsky{at}ahrq.hhs.gov
The increasing premium placed on making health-care decisions and assessing quality of care using the best available evidence highlights the importance of transparent, thoughtful, and rigorous guideline development. The American College of Chest Physicians (ACCP) has been a leader in guideline development; and their approach, outlined in this issue(see page 1015),1 describes an evolution in processes and methodologies for developing, assessing, and implementing clinical practice guidelines.
Why Process Counts
Clinical practice guidelines have increasing potential to influence how medical care is delivered and measured. Current interest in quality and value depends on scientifically valid quality measures most often derived from clinical practice guidelines. Leadership from physician professional organizations is vital to public confidence that "report cards" are meaningful, and to practicing physicians who look to their professional home for reassurance that metrics are credible and in the best interest of their patients.2 In short, clinical practice guidelines are the "face" of systematic reviews and the foundation for quality measures, clinical decision support systems, and pay-for-performance criteria; so how they are developed is instrumental to the ultimate goal of improving health outcomes.3 Being clear and explicit about guideline development is no longer an option, it is an expectation, and a new and important dimension of professionalism.
The scientific and medical communities continue to struggle with conflict of interest and how to control and mitigate its impacts. Studies4 have shown that disclosure alone does not mitigate bias. Articles in nonmedical literature5 have questioned the relationship between industry, physicians, and decision making. Biomedical and medical journal editors have endorsed clear standards of reporting conflict of interest,6 and it is critical that guideline developers not only report but manage conflicts so that the final guideline is untainted and trustworthy. The ACCP has outlined a detailed algorithm for managing many aspects of guideline development, including conflicts of interest, which provide both guideline developers and users clear direction.
Assessing and distilling the best evidence is only the beginning: continued evolution of science requires that guidelines be updated to remain credible. A logical and practical process for assessing when a guideline needs to be updated has challenged guideline developers for decades. The ACCP has addressed the critical issue of keeping their guidelines updated. Keeping guidelines current is vital to their acceptance by clinicians and to provide a mechanism for getting research findings into practice much sooner than would otherwise occur. Anyone who has been a guideline developer knows that keeping a guideline current is a large undertaking, and there remains much to learn about how to do this efficiently.
The Future Is Important
Guideline development has advanced steadily, embracing more rigorous evidence standards, explicit methods, broad disciplinary participation, and recognition of the importance of understanding patient perspectives. The knowledge that guidelines alone do not change behavior, but are necessary adjuncts, has spurred new and creative interest into where they can be strengthened to advance quality of patient care.
A renewed recognition that medical decision making is complex, in part because patients are complex, often presenting with multiple comorbid conditions, has driven a desire to develop integrated guidance for care of complex cases. How to do this well is a challenge from an evidence and a multidisciplinary perspective. But since patients often do not come with discrete conditions, this will become the "next frontier" in guideline development. Advances in health information technology will soon make it possible to enhance guidelines frequently based on empirical experience in clinical care.
As guideline development moves from discrete interventions applied in a single setting to strategies that ultimately encompass delivering care to patients in a variety of settings, so too will the appearance of guidelines change. Lessons learned from using paper-based guidelines show that access to knowledge must be close to the point of decision making. The Internet has brought guidelines closer to the point of care but still several steps removed. Health information technology is increasingly making relevant information available at the point of decision making. Often, this looks very different than a paper or Internet-based guideline.
At its best, health information technology can integrate guideline recommendations into the actual encounter, making "the right thing to do, the easy thing to do." There are things that need to happen to make this work well, however. Guideline statements need to reflect the environment in which they are interpreted. In other words, if a guideline developer does not define "routine" or "periodic," someone else will. That may be just fine, or it may not be. Guideline developers need to make these tough distinctions early so that information systems in which guidelines are implemented have the best direction possible. In the end, it is getting the recommendations used that counts; and to do this, the guideline may no longer look like what it began as: the information is the same but the delivery is very different.
Conclusions
Clinical practice guidelines remain an important tool and mechanism to drive evidence-based decision making and quality reporting. The ACCP has continued to move the field forward with its explicit and rational approach to development and has addressed some difficult issues along the way. No doubt 10 years from now, guidelines will have evolved to become more adaptable to complex cases and to the information systems that deliver them to the point of care. Underpinning all these changes will be a well-developed guideline using explicit and transparent processes. The ACCP has brought us that much closer.
Footnotes
The views expressed in this editorial are those of the authors and do not necessarily reflect the official position of the US Department of Health and Human Services.
Ms. Slutsky is the Vice-Chair and a member of the Executive Board of the Guidelines International Network.
The authors have no conflicts of interest to disclose.
References
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