On the goodness of recommendations: the changing face of practice parameters.

AS THE CURRENT DEBATE OVER HEALTH CARE REFORM INTENSIFIES AND THE MANDATE TO CONTROL EVER-ESCALATING HEALTH CARE COSTS MOVES TO the top of the political agenda, evidence based medicine is becoming increasingly recognized as a critical instrument to help manage these issues. Evidence based medicine may be globally defined as the judicious use of the best current evidence in making decisions about the care of the individual patient. While the term “evidence based medicine” (EBM) first appeared in the medical literature in 1990,1 traces of EBM origins date back to ancient Greek and Chinese medicine. The Standards of Practice Committee was founded in the early 1990s and produced some of the first evidence based practice guidelines in medical practice (Figure 1). Figure 1 Cumulative practice parameter products of the Standards of Practice Committee In the EBM world, “evidence” is generally considered to consist of published opinions and the results of various trials or studies regarding health care. Deciding what is “the best current evidence” necessitates development of a system that can be used to judge which published conclusions to trust more and which less. The last two decades have seen the emergence of a multitude of evidence grading systems with varying successes. The Standards of Practice Committee (SPC) of the American Academy Sleep of Medicine (AASM) has developed 31 practice parameter/best practices papers based on the systematic review of existing literature in an effort to provide diagnostic and treatment strategies for typical practitioners. The Oxford Levels of Evidence has been the primary grading system used by the SPC to grade evidence and assign recommendations. A significant advantage of this system is that it lends itself to many types of studies covering various aspects of the medical management of patients, including diagnosis as well as therapeutic interventions. However, inherent limitations in this system (as well as others) include the lack of a framework to separately evaluate the rigor of available evidence and the strength of recommendations. There has been an implicit implication that strong evidence leads to strong recommendations. This approach ignores the many other factors that are considered in developing recommendations, such as values, effect size, risks, costs, and alternative options. Such limitations may result in misinterpretation of the assigned recommendations by practitioners, insurance companies, and policy makers. In an effort to incorporate the strengths of preexisting grading systems while addressing their inadequacies, guideline developers, methodologists, and clinicians collaborated to form the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) Working Group.2 Since then, a number of international and national professional organizations have adopted the GRADE system either in its original format or with some modifications for guideline development. This document intends to explicate the advantages offered by the GRADE system over our previously used evidence assessment system and elucidate the modified GRADE system that is being adopted for implementation by the SPC and Task Forces commissioned by the AASM leadership.