CPG Critique

7/27/2019 CPG Critique

1/39

Critiquing Clinical Practice

Guidelines

Erin L. Giudice, MD


2/39

Outline

Answerable Clinical Question Sources of clinical practice guidelines

The Users Guide to EBMCPGs Other Attributes of Good CPGs Evidence regarding physicians following

guidelines, barriers to implementation,and need for updating


3/39

Sources of Clinical PracticeGuidelines

Professional societiesAmerican Academy of Pediatrics (general)

Other specialties (eg. American Academy ofChild and Adolescent Psychiatry for ADD)

Non-profit organizations

Institute for Clinical Systems Improvement Hospitals


4/39

How to Use a Clinical PracticeGuideline (CPG)

Are the results of the study(recommendations) valid?

What were the results(recommendations)? Will the results (recommendations) help

me in caring for my patients? Hayward, RS. Et al, EBM working group. Based

on the Users Guide to EBM and reproduced withpermission of JAMA (1995, AMA);http://www.cche.net/priniples/guideline.asp


5/39

Are the results of the study (CPG)valid? Primary Guides:

Were all important options and outcomesclearly specified?


6/39

Are the results of the study (CPG)valid? Primary Guides:

Was an explicit and sensible process used toidentify, select, and combine evidence?

See Methods section! (Examples:) multidisciplinary committee of experts

careful literature review (by McMaster EBM center):searched using multiple databases (Medline,

PsycINFO, Cochrane), with focused questions Selection criteria: mostly RCTs, peer-reviewed


7/39

Are the results of the study (CPG)valid? Secondary Guides

Was an explicit and sensible process usedto consider the relative value of different

outcomes? How did the guideline creators grade the

quality of evidence for overall questions

and strength of recommendations?


8/39


Is the guideline likely to account forimportant recent developments?

At the time it was created? Currently?


9/39


Has the guideline been subject to peerreview and testing?

Draft guideline reviewed by AAP and/orother outside organizations (prior topublication)?


10/39


Any formal testing regarding if patientoutcomes are better (or equivalent at

decreased cost) after guideline?Any studies/articles published regarding

the use of this guideline?

Do review articles site this as standard ofcare?


11/39

What were the results?

Are practical, clinically important

recommendations made?


12/39


How strong are the recommendations? What is the strength of evidence used?

Does the CPG specify for eachrecommendation all of the evidencesupporting it (and relative strength of

different studies)?


13/39


What is the impact of uncertaintyassociated with the evidence and values

used in the guidelines?


14/39

How will the results help me in

caring for my patients?

Is the primary objective of the guideline

consistent with your objective? Does this CPG answer your clinical

question?


15/39

How will the results help me in

caring for my patients?Are the recommendations applicable to

your patients?

Are your patients similar to those targeted bythe CPG?

Are the treatments described possible in yoursetting?

Do values assigned to various outcomes differfrom your patients preferences?


16/39

Other Attributes of Good Clinical

Practice GuidelinesValidity: data on patient outcomes Reliability and reproducibility: likely other

experts would have similar recs Clinical applicability and flexibility:

guideline addresses patients it should

apply to (and exceptions) Clarity: logical and easy to follow


17/39

Other Attributes of Good Clinical

Practice Guidelines Multidisciplinary process Scheduled Review

Documentation: good description inmethods of how each study was gradedand how overall evidence was graded


18/39

Evidence regarding physicians

following this guideline Example: Use of practice guidelines in the

primary care of children with ADHD

Rushton, JL et al, Peds July 2004: 91.5% pediatricians aware of guideline(vs. 59.8% of family physicians)

53-81% adherence to each of 4 reccs inguidelines, (in survey of primary carephysicians)


19/39

Barriers to implementation of

this guideline Ex: Use of practice guidleines in the primary

care of children with ADHD Peds 7/04:

Only 32.5% of clinicians agreed their communityhad adequate, accessible mental healthresources

Half (50.1%) of physicians reported thatinsurers limit coverage for assessment andtreatment of ADHD


20/39

Is this guideline still useful?

Does it need updating? Regarding overall management? Have new medications (including new

classes of medications) been introducedsince this guideline was published?

Other more recent research on the

disease?


21/39

Additional References (1)

Internet Sources of Guidelines: National Guideline Clearinghouse:

www.guideline.gov

Guide to Clinical Preventive Services:http://text.nlm.nih.gov/ftrs/dbaccess/cps ;Agency for Healthcare Research and Quality(AHRQ): www.ahrq.gov

American College of Physicians:http://www.acponline.org/clinical_information/guidelines/
http://www.guideline.gov/http://text.nlm.nih.gov/ftrs/dbaccess/cpshttp://www.ahrq.gov/http://www.acponline.org/clinical_information/guidelines/http://www.acponline.org/clinical_information/guidelines/http://www.acponline.org/clinical_information/guidelines/http://www.acponline.org/clinical_information/guidelines/http://www.ahrq.gov/http://text.nlm.nih.gov/ftrs/dbaccess/cpshttp://www.guideline.gov/


22/39

Additional References (2)

American Academy of Family Physicians:http://www.aafp.org/online/en/home/clinical/clinicalrecs.html

American Academy of Pediatrics:

http://aappolicy.aappublications.org/

Woolf et al. Potential benefits, limitations, andharms of clinical guidelines. BMJ. 1999;318:527-530.
http://www.aafp.org/online/en/home/clinical/clinicalrecs.htmlhttp://www.aafp.org/online/en/home/clinical/clinicalrecs.htmlhttp://aappolicy.aappublications.org/http://aappolicy.aappublications.org/http://www.aafp.org/online/en/home/clinical/clinicalrecs.htmlhttp://www.aafp.org/online/en/home/clinical/clinicalrecs.html


23/39


24/39


25/39


26/39


27/39


28/39


29/39


30/39


31/39


32/39


33/39


34/39


35/39


36/39


37/39


38/39


39/39

CPG Critique

Documents

Transcript of CPG Critique