Crafting practice guidelines in the world of evidence-based medicine.

As recently as the early 1990’s, medical treatment was practiced as it had been for centuries: if a treatment seemed logical and worked, it became part of the common practice.(1) Randomized controlled trials and other high-level evidence scientific studies were an afterthought. However, in today’s changing economic climate, evidence-based medicine has become an important movement in American medicine to improve quality of healthcare and decrease cost.(2, 3) Although making patient-care decisions based on high-impact evidence is a desirable goal, with Medline adding over 600,000 new articles a year (nearly 2000 a day!)(4), it is nearly impossible for any physician to keep abreast of all the relevant evidence from the existing literature. Practice guidelines aim to bridge the gap between research and practice by doing what few physicians have time to do - staying current with the literature. Most physicians are unable to read all the relevant literature and synthesize the results into recommendations to achieve best practice. Practice guidelines embrace evidence-based medicine by rigorously distilling the highest level of evidence from the literature in an effort to help physicians in the compassionate and scientific treatment of patients. Practice guidelines are a series of condition- and population-specific recommendations, often published by professional specialty societies such as the American Society of Plastic Surgeons, for patient management. Guidelines can provide recommendations on which diagnostic tests to use, which treatments or medication to provide or they may recommend that no action be taken at all. They provide evidence-based guidance to physicians who have not had the time to read all the literature. Practice guidelines are created with the goal to reduce inappropriate variations in medical practice by assuring all patients experience consistent, efficient, high-quality care. Decreasing practice variations, which is the genesis of the outcomes movement, can reduce morbidity and mortality, improve patient quality of life, and promote equality in treatment.(5, 6) Despite these potential benefits, there are physicians who oppose the creation of guidelines. They claim that practice guidelines promote “medical laziness,” encourage “cookbook medicine” and compromise the art of medical practice.(7, 8) These views are contrary to the intent of evidence-based medicine and the practice guidelines. In contrast to quality measures that seek to distinguish between good and poor quality practices in order to assess rewards and penalties, practice guidelines only make recommendations regarding what constitutes the best evidence in the practice.(9) Table 1 illustrates the differences between practice guidelines and quality measures. Table 1 Practice Guidelines vs. Quality Measures Rather than a strict set of steps, as in quality measures, the use of practice guidelines is analogous to consulting a cookbook to guide the creation of a dish. The recipes in a cookbook do not prevent a cook from tossing a handful of basil into a dish if the cook feels it would improve the flavor. Along the same concept, practice guidelines only suggest the best practice for treating a particular condition.(9) Practice guidelines are not a stand-in for the knowledge that one gains from meaningful patient interaction. Only the treating physician knows the quirks and circumstances of a particular patient. Ultimately the treatment decision must be a shared decision-making process between the physician and the patient by using the best scientific evidence from the literature. Practice guidelines have the potential to have substantial impact. They may be disseminated on a national, or even international, scale or become part of quality of care metrics, even though practice guidelines serve as guides and are not meant to be quality measures. Nevertheless, because any guideline may be used in these ways, practice guidelines should be carefully constructed. (Figure 1) This process takes time, often months rather than days or weeks, and can be costly, if performed correctly. Throughout this manuscript, we will be referring to the process used to develop the American Academy of Orthopedic Surgeons’ (AAOS) September 2008 Clinical Practice Guideline on the Treatment of Carpal Tunnel Syndrome as an example.(10) The senior author (KCC) was part of the panel in constructing this practice guideline, and the practical experience obtained in this structured process can be instructive in crafting future projects. The guideline writing process is intensively methodical, but the production of high-quality, evidence-based practice guidelines is a process that must be deliberate and thoughtful. Figure 1 The steps required in practice guideline writing. Note the iterative nature of literature review, guideline writing and dissemination.