Compliance with clinical practice guidelines in family physicians managing worker''s compensation board patients with acute lower back pain

BACKGROUND CONTEXT: Family physician compliance with acute lower back pain clinical practice guidelines remains uncertain. PURPOSE: To determine the degree of guideline compliance of family physicians managing patients with workers' compensation claims and acute mechanical lower back pain. STUDY DESIGN: Observational study. PATIENT SAMPLE: One hundred thirty-nine family physicians in British Columbia. OUTCOME MEASURES: Compliance with guideline recommendations for history, examination procedures, diagnostic testing and treatments. METHODS: Physician workers' compensation board patient reports for acute lower back pain without leg symptoms and not greater than 2 to 3 weeks duration were scored for guideline adherence up until 12 weeks after onset. RESULTS: Physicians demonstrated a high degree of compliance with the guideline-recommended history, examination procedures and medications, but low compliance with recommended imaging and many treatment recommendations. CONCLUSIONS: Recently published clinical practice guidelines regarding the management of patients with acute mechanical lower back pain have not been fully implemented into the patterns of practice of the family physicians.     

Clinical practice guidelines in the intensive care unit: a survey of Canadian clinicians’ attitudes

PURPOSE: To understand clinicians' perceptions regarding practice guidelines in Canadian intensive care units (ICUs) to inform guideline development and implementation strategies. METHODS: We developed a self-administered survey instrument and assessed its clinical sensibility and reliability. The survey was mailed to ICU physicians and nurses in Canada to determine local ICU guideline development and use, and to compare physicians' and nurses' attitudes and preferences towards guidelines. RESULTS: The survey was completed by 51.6% (565/1095) of potential respondents. Although less than half reported a formal guideline development committee in their ICU, 81.0% reported that guidelines were developed at their institutions. Of clinicians who used guidelines in the ICU, 70.2% of nurses and 42.6% of physicians reported using them frequently or always. Professional society guidelines (with or without local modification) were reportedly used in most ICUs, but physicians were more confident than nurses of their validity (P<0.001). Physicians considered endorsement of guidelines by a colleague more relevant for enhancing guideline use than did nurses (P<0.001). Nurses considered low risk of the guideline and whether the guideline is consistent with their practice (P<0.001) to be more relevant to guideline uptake than did physicians (P<0.001). Lack of agreement with recommendations was a more important barrier to use of guidelines for physicians than for nurses (P<0.001). CONCLUSIONS: Many Canadian institutions locally develop guidelines, and many ICU physicians and nurses report using them. Planning implementation strategies according to clinician preferences may increase guideline use. The nature of the differences in attitudes towards guidelines between nurses and physicians, and their impact on clinician adherence to guidelines requires further exploration.     

Exploration of physicians' recommendations for activities in chronic low back pain

STUDY DESIGN: A mailed survey of 142 practicing physicians (63 orthopedic spine surgeons and 79 family physicians) inquiring about their expertise and experience with chronic low back pain, their pain attitudes and beliefs, and recommendations about the appropriate level of function for chronic back pain patients. OBJECTIVES: To explore physicians' recommendations for activity and work for patients with chronic low back pain and to determine factors that might influence these recommendations. SUMMARY OF BACKGROUND DATA: Physicians continuously are asked to recommend the appropriate level of activities and work for patients with chronic low back pain. Although these recommendations can have a significant impact on patients' lives, little is known about the factors that shape recommendations. METHODS: Mailed surveys included questions inquiring about the physicians' demographics, training, and experience in low back pain, the Health Care Providers' Pain and Impairment Relationship Scale, and three vignettes of work-disabled, chronic low back pain patients. After each vignette, physicians rated their perceptions of severity of symptoms and pathology and recommendations for work and daily activities through five graded responses. Three mailings were done within 4 weeks to maximize the response rate. The association of each variable with work and activity recommendations was statistically explored. To assess the influence of clinical expertise on recommendations, the responses of orthopedic spine surgeons were compared with those of family physicians. Test-retest reliability was assessed with a second mailing of the questionnaire to all initial responders. RESULTS: Sixty-five percent of the orthopedic surgeons and 52% of the family physicians responded to the survey. Thirty-nine percent of the initial responders completed the reliability survey. The survey instrument demonstrated modest reliability, with identical recommendations for activities and work occurring 57% of the time. In general, a wide range of activities and work was recommended, with most physicians recommending avoidance of painful activities or greater restrictions. Orthopedic spine surgeons were slightly less restrictive in their activity recommendations compared with family physicians. Most physicians demonstrated some consistency in their pattern of recommendations when compared with their colleagues. Physicians' pain attitudes and belief influenced their recommendations, as did their perception of the severity of the patients' clinical symptoms. CONCLUSIONS: Physicians' recommendations for activity and work to patients with chronic back pain vary widely and frequently are restrictive. These recommendations reflect personal attitudes of the physicians as well as factors related to the patients' clinical symptoms.     

Formulation of Japanese Orthopaedic Association (JOA) clinical practice guideline for the management of low back pain- the revised 2019 edition

BackgroundThe latest clinical guidelines are mandatory for physicians to follow when practicing evidence-based medicine in the treatment of low back pain. Those guidelines should target not only Japanese board-certified orthopaedic surgeons, but also primary physicians, and they should be prepared based entirely on evidence-based medicine. The Japanese Orthopaedic Association Low Back Pain guideline committee decided to update the guideline and launched the formulation committee. The purpose of this study was to describe the formulation we implemented for the revision of the guideline with the latest data of evidence-based medicine.MethodsThe Japanese Orthopaedic Association Low Back Pain guideline formulation committee revised the previous guideline based on a method for preparing clinical guidelines in Japan proposed by Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014. Two key phrases, “body of evidence” and “benefit and harm balance” were focused on in the revised version. Background and clinical questions were determined, followed by literature search related to each question. Appropriate articles were selected from all the searched literature. Structured abstracts were prepared, and then meta-analyses were performed. The strength of both the body of evidence and the recommendation was decided by the committee members.ResultsNine background and nine clinical qvuestions were determined. For each clinical question, outcomes from the literature were collected and meta-analysis was performed. Answers and explanations were described for each clinical question, and the strength of the recommendation was decided. For background questions, the recommendations were described based on previous literature.ConclusionsThe 2019 clinical practice guideline for the management of low back pain was completed according to the latest evidence-based medicine. We strongly hope that this guideline serves as a benchmark for all physicians, as well as patients, in the management of low back pain.     

Arthroscopic acromioplasty: a comparison between workers' compensation and non-workers' compensation populations

BACKGROUND: The purpose of the present prospective study was to analyze a consecutive series of patients with subacromial impingement syndrome who were managed with arthroscopic acromioplasty by a single surgeon. METHODS: A consecutive series of 106 patients (106 shoulders) with a mean age of 44.7 years (range, twenty to seventy years) was analyzed after a mean duration of follow-up of thirty-two months. The Workers' Compensation group included forty patients (twenty-five men and fifteen women) with a mean age of 41.7 years. The non-Workers' Compensation group included sixty-six patients (thirty-two men and thirty-four women) with a mean age of 46.5 years. The work-demand level was categorized according to the Dictionary of Occupational Titles from the United States Department of Labor. Previously unrecognized intra-articular pathological changes were categorized with use of consistent criteria. Workers' Compensation status, the work-demand level, and the presence of associated intra-articular pathological changes were analyzed for their effect on outcome scores and time to return to full-duty work. RESULTS: The mean outcome scores for the entire population showed significant improvement when the preoperative values were compared with the postoperative values; specifically, the American Shoulder and Elbow Surgeons (ASES) score improved from 41.8 to 86.9, the Simple Shoulder Test (SST) score improved from 5.1 to 10.0, and the visual analog scale (VAS) for pain improved from 6.0 to 1.1 (p < 0.05). Postoperatively, there was no significant difference in the mean outcome scores between the Workers' Compensation and non-Workers' Compensation groups or between different work-demand levels. There was, however, a significant difference in the average time to return to full-duty work (13.7 weeks in the Workers' Compensation group compared with 9.1 weeks in the non-Workers' Compensation group; p = 0.0001), with the Workers' Compensation group having relatively heavier work-demand levels. Intra-articular pathological findings did not affect the outcome scores, but pathological findings that changed treatment were associated with a longer time to return to work (p = 0.04). CONCLUSION: Arthroscopic acromioplasty consistently provided a good surgical outcome and the ability to return to work in both the Workers' Compensation and non-Workers' Compensation populations. The work-demand level had a direct effect on the time to return to full duty, regardless of Workers' Compensation status. Patients, physicians, therapists, and employers may benefit from the knowledge of these expected outcomes and realistic time-frames for return to work.     

An updated overview of clinical guidelines for the management of non-specific low back pain in primary care

The aim of this study was to present and compare the content of (inter)national clinical guidelines for the management of low back pain. To rationalise the management of low back pain, evidence-based clinical guidelines have been issued in many countries. Given that the available scientific evidence is the same, irrespective of the country, one would expect these guidelines to include more or less similar recommendations regarding diagnosis and treatment. We updated a previous review that included clinical guidelines published up to and including the year 2000. Guidelines were included that met the following criteria: the target group consisted mainly of primary health care professionals, and the guideline was published in English, German, Finnish, Spanish, Norwegian, or Dutch. Only one guideline per country was included: the one most recently published. This updated review includes national clinical guidelines from 13 countries and 2 international clinical guidelines from Europe published from 2000 until 2008. The content of the guidelines appeared to be quite similar regarding the diagnostic classification (diagnostic triage) and the use of diagnostic and therapeutic interventions. Consistent features for acute low back pain were the early and gradual activation of patients, the discouragement of prescribed bed rest and the recognition of psychosocial factors as risk factors for chronicity. For chronic low back pain, consistent features included supervised exercises, cognitive behavioural therapy and multidisciplinary treatment. However, there are some discrepancies for recommendations regarding spinal manipulation and drug treatment for acute and chronic low back pain. The comparison of international clinical guidelines for the management of low back pain showed that diagnostic and therapeutic recommendations are generally similar. There are also some differences which may be due to a lack of strong evidence regarding these topics or due to differences in local health care systems. The implementation of these clinical guidelines remains a challenge for clinical practice and research.     

Guidelines for cardiac management in noncardiac surgery are poorly implemented in clinical practice: results from a peripheral vascular survey in the Netherlands

BACKGROUND: The American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery recommend an algorithm for a stepwise approach to preoperative cardiac assessment in vascular surgery patients. The authors' main objective was to determine adherence to the ACC/AHA guidelines on perioperative care in daily clinical practice. METHODS: Between May and December 2004, data on 711 consecutive peripheral vascular surgery patients were collected from 11 hospitals in The Netherlands. This survey was conducted within the infrastructure of the Euro Heart Survey Programme. The authors retrospectively applied the ACC/AHA guideline algorithm to each patient in their data set and subsequently compared observed clinical practice data with these recommendations. RESULTS: Although 185 of the total 711 patients (26%) fulfilled the ACC/AHA guideline criteria to recommend preoperative noninvasive cardiac testing, clinicians had performed testing in only 38 of those cases (21%). Conversely, of the 526 patients for whom noninvasive testing was not recommended, guidelines were followed in 467 patients (89%). Overall, patients who had not been tested, irrespective of guideline recommendation, received less cardioprotective medications, whereas patients who underwent noninvasive testing were significantly more often treated with cardiovascular drugs (beta-blockers 43% vs. 77%, statins 52% vs. 83%, platelet inhibitors 80% vs. 85%, respectively; all P < 0.05). Moreover, the authors did not observe significant differences in cardiovascular medical therapy between patients with a normal test result and patients with an abnormal test result. CONCLUSION: This survey showed poor agreement between ACC/AHA guideline recommendations and daily clinical practice. Only one of each five patients underwent noninvasive testing when recommended. Furthermore, patients who had not undergone testing despite recommendations received as little cardiac management as the low-risk population.     

Practice patterns versus practice guidelines in pediatric otitis media.

OBJECTIVE: To study the practice patterns of physicians and their adherence to an evidence-based practice guideline (PG) on pediatric otitis media with effusion. We hypothesized that overall knowledge of the recommendations from the guidelines would be less than 75%, and that specialist physicians would have better knowledge of the recommendations than generalist physicians. METHODS: We performed a survey study of 1167 otolaryngologists, pediatricians, and pediatric otolaryngologists. Each physician was sent a 6-item survey asking about their practice patterns and treatment preferences for young children with otitis media with effusion. We compared responses between different specialties. RESULTS: The overall response rate was 48%. Only 8 (1.4%) of the 558 responding physicians answered all 6 items congruent with the PG. Overall, pediatricians, otolaryngologists, and pediatric otolaryngologists had similar total scores, but different scores on individual items. CONCLUSIONS: These results indicate that the practice patterns of pediatricians, otolaryngologists, and pediatric otolaryngologists differ from the recommendations of an evidence-based PG. In particular, 2 items covering key treatment recommendations were answered in agreement with the PG by fewer than half of the physicians. It is not clear from this study whether these discrepancies were due to poor dissemination or knowledge concerning the PG, or disagreement with its recommendations.     

Influence of clinical guidelines on medical practitioners

Evidenced-based clinical guidelines for diagnosing and treating hepatocellular carcinoma patients were published in 2005, which were edited by the executive members of the Liver Cancer Study Group of Japan (Chief Editor, Professor Masatosi Makuuchi, MD). This article presents the results of two surveys investigating the validity and usefulness of those guidelines. The author's opinions regarding the evaluation of the guidelines and guideline-based clinical practice are also presented. The surveys revealed that the guidelines are well known and thought to be useful by medical practitioners. The guidelines had changed the therapeutic strategy of 20% of experts in the field. However, 43% of experts and 30% of nonexperts believed that the guidelines restricted their medical discretion. Additionally, the percentage of physicians who felt that medical malpractice suits would increase exceeded those who did not. However, the guidelines do not provide clear recommendations in about 45% of diagnostic and therapeutic points because of a lack of evidence. The recommendations on these points in the guidelines require the commonsense discretion of physicians. The guidelines should be followed based on an understanding of biology and medicine, and not based on dogmatism.     

Renal cell carcinoma guideline

OBJECTIVES: The European Association of Urology (EAU) Guideline Group for renal cell carcinoma (RCC) prepared this guideline to help urologists assess the evidence-based management of RCC and to incorporate the guideline recommendations into their clinical practice. METHODS: The recommendations provided in the current guideline are based on a systematic literature search using MedLine, the Cochrane Central Register of Controlled Trials, and publications and review articles. RESULTS: A limited number of prospective randomised studies are available with high-level evidence. Most publications concerning RCC are based on retrospective analyses, including some larger multicentre validation studies and well-designed controlled studies. CONCLUSIONS: It must be stressed that the current guideline contains information for the treatment of an individual patient according to a standardised general approach. Updated recommendations concerning diagnosis, treatment, and follow-up can improve the clinical handling of patients with RCC.     

Patient compliance in avoiding wrong-site surgery

BACKGROUND: Wrong-site orthopaedic surgery is an uncommon, devastating, and preventable complication. The sole responsibility for avoiding this inadvertent event has historically been placed on physicians, nurses, and ancillary health-care personnel. Very little attention has been focused on the role of the patient. The successful outcome of any surgical or medical intervention requires an interactive doctor-patient relationship. The hypothesis of this study was that a substantial number of patients who undergo elective orthopaedic surgery do not comply with instructions designed specifically to prevent wrong-site surgery. METHODS: We prospectively evaluated the frequency with which 100 consecutive patients in a private foot-and-ankle practice followed the explicit preoperative instruction, before they underwent elective orthopaedic surgery, to mark "NO" on the extremity that was not to be operated on. Full compliance was defined as a mark on the correct extremity consistent with the instructions. Partial compliance was defined as a mark that was different from that requested by the specific preoperative instructions, and noncompliance was defined as the absence of any mark. Specific demographic and surgical factors were recorded from medical charts and compared between compliant and noncompliant patients. RESULTS: Fifty-nine of the 100 patients marked the extremity correctly, thirty-seven made no mark, and four were considered partially compliant. Of the ten patients with a Workers' Compensation claim, seven were noncompliant compared with thirty (33%) of the ninety patients who had not made a Workers' Compensation claim (p = 0.023). Patients who had had a previous related surgical procedure also had a significantly higher rate of noncompliance (51%; nineteen of thirty-seven) compared with those with no previous surgery (29%; eighteen of sixty-three; p = 0.023). CONCLUSIONS: A surprisingly high number of patients do not comply with explicit preoperative instructions created specifically to prevent wrong-site surgery. This behavior suggests that patients expect the system to "take care of everything," despite solicitation of their active participation to avoid such adverse events. Although physicians and related health-care personnel certainly have the greatest responsibility to provide the highest possible quality of care, patients undergoing surgery must be encouraged to take a more active role in their health care in order to optimize outcome and minimize risk.     

Uptake of adjuvant breast cancer treatments recommended by multi‐disciplinary meetings

Background

Adjuvant therapy for breast cancer is routinely discussed and recommended in multi‐disciplinary meetings (MDMs). Current literature explores how treatments received by patients differ from national guidelines; however, it does not explore whether treatment is concordant with MDMs. This study provides an Australian perspective on the uptake of MDM recommendations and reasons for non‐concordance.

Methods

A retrospective cohort study of patients with breast cancer presented at The Royal Melbourne Hospital MDM in 2010 and 2014 to investigate the concordance between MDM recommendations and treatment received.

Results

The study group comprised 441 patients (161 from 2010 and 280 from 2014). A total of 375 patients were included in the analyses. Overall, 82% of patients had perfect concordance between recommended and received treatment for all modes of adjuvant therapy. Concordance to endocrine therapy was higher for invasive cancers than ductal carcinoma in situ (97% versus 81%, P < 0.0001). Concordance to radiotherapy was high and did not differ according to type of cancer or surgery (ranging from 88 to 91%). Concordance to chemotherapy recommendations was high overall (92%) and did not vary with nodal status. Women aged over 65 years were least likely to be recommended for adjuvant therapy but most likely to concordant with the recommendation.

Conclusions

Uptake of MDM‐recommended treatments is high. There is a minority of patients in whom MDM recommendations are not followed, highlighting that there are extra steps between recommendations at an MDM and decisions with patients. More attention to this issue is appropriate, and the reasons for non‐concordance warrant further study.     

Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain

Background contextThe North American Spine Society's (NASS) Evidence Based Clinical Guideline for the Diagnosis and Treatment of Low Back Pain features evidence-based recommendations for diagnosing and treating adult patients with nonspecific low back pain. The guideline is intended to reflect contemporary treatment concepts for nonspecific low back pain as reflected in the highest quality clinical literature available on this subject as of February 2016.PURPOSEThe purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with nonspecific low back pain. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition.Study designThis is a guideline summary review.MethodsThis guideline is the product of the Low Back Pain Work Group of NASS’ Evidence-Based Clinical Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guideline was submitted to an internal and external peer review process and ultimately approved by the NASS Board of Directors.ResultsEighty-two clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature.ConclusionsThe evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with nonspecific low back pain. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx     

Implementing nursing practice guidelines: a complex undertaking.

Clinical practice guidelines have been proposed to significantly reduce the gap between available scientific evidence and clinical practice. Evidence-based guidelines are also being produced at an ever-increasing pace. However, guidelines do not implement themselves, and the research to support implementation does not provide straightforward answers. What works in one setting does not necessarily work in another. In short, guideline implementation and change of practice is complex and messy. The purpose of this article is to discuss the implementation of clinical practice guidelines using the Promoting Action on Research Implementation in Health Services framework. More specifically, 3 key components are highlighted: (1) the evidence base for guideline recommendations, (2) the clinical context where guidelines are to be implemented, and (3) the nature of facilitation needed to ensure a successful change process. An overview of the literature in the field is provided, and the authors' experiences are shared, and a few recommendations are tentatively provided.     

High-intensity focused ultrasound for prostate cancer: a practice guideline

Objective:

The aim of this practice guideline was to develop evidence-based recommendations for clinicians on the use of high-intensity focused ultrasound (HIFU) in patients with localized prostate cancer.

Methods:

The guideline was developed using the methods of Cancer Care Ontario’s Program in Evidence-Based Care (PEBC). The core methodology of the PEBC’s guideline development process is systematic review. A comprehensive literature search was undertaken to identify high-quality studies, reviews and other practice guidelines on the use of HIFU in prostate cancer. The evidence formed the basis of the recommendations, which were reviewed and amended where necessary, by clinical experts in medical and radiation oncology and urology.

Results:

The literature review yielded limited evidence. No randomized controlled trials or meta-analyses comparing HIFU with currently accepted management approaches were identified. The body of evidence is primarily based on data from case series. Internal feedback was provided by the PEBC Genitourinary Disease Site Group membership and the Report Approval Panel. External peer review included targeted review by clinical experts specifically requested to comment on the guideline, and professional consultation through an online survey of health care professionals.

Conclusion:

HIFU is currently not recommended as an alternative to accepted curative treatment approaches for localized prostate cancer.     

Japanese Orthopaedic Association 2019 Guidelines for osteonecrosis of the femoral head

PurposeThe Clinical Practice Guidelines for Osteonecrosis of the Femoral Head (ONFH) 2019 Edition, written by the working group for ONFH guidelines of the Japanese Investigation Committee (JIC) for ONFH under the auspices of the Japanese Ministry of Health, Labour, and Welfare and endorsed by the Japanese Orthopaedic Association, were published in Japanese in October 2019. The objective of this guideline is to provide a support tool for decision-making between doctors and patients.MethodsProcedures for developing this guideline were based on the Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014, which proposed an appropriate method for preparing clinical guidelines in Japan.ResultsThis clinical practice guideline consists of 7 chapters: epidemiology; pathology; diagnosis; conservative therapy; surgical treatment: bone transplantation/cell therapy; surgical treatment: osteotomy; and surgical treatment: hip replacement. Twelve background questions and 13 clinical questions were determined to define the basic features of the disease and to be addressed when deciding treatment in daily practice, respectively.ConclusionsThe clinical practice guidelines for the ONFH 2019 edition will be useful for physicians, investigators, and medical staff in clinical practice, as well as for patients, during the decision-making process when defining how to treat ONFH.     

Recommandations européenes (COST B 13) en matiè de prévention et de prise en charge de la lombalgie non spécifique

Objectives. To produce guidelines based on scientific evidence for the management of low back pain. These guidelines were developed within the framework of the COST Action B13 “Low back pain : guidelines for its management”, issued by the European Commission, Research Directorate-general, Department of Policy, Coordination and Strategy.Methods. Thirty eight experts in the field of low back pain coming from 13 different European countries have contributed to these guidelines. The experts were assigned to three working groups. The group 1 has formulated guidelines for the management of acute low back pain, the group 2 has developed guidelines for the management of chronic low back pain and, finally, the group 3 has proposed guidelines for the prevention in low back pain. The evidence underpinning the guidelines was retrieved through systematic searches of the scientific literature up to the end 2003. Systematic review, randomised controlled trials, and existing guidelines were included. The methodological quality of the selected articles was evaluated using the scoring system developed by the “Cochrane Back Review Group”.Results and conclusion. This paper is a summary in French of the recommendations based on scientific evidence that should be taken into consideration by physicians, health care providers and policy makers when dealing with patients suffering from low back pain. Nevertheless, many aspects of care need to be validated before recommendations can be issued.     

Evidence-based clinical practice guidelines for prostate cancer: the need for a unified approach

PURPOSE OF REVIEW: Clinical practice guidelines are being increasingly recognized as critically important to an evidence-based practice. This article reviews the different approaches used by leading urological organizations to the development of prostate cancer guidelines. It further introduces the recommendations of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) working group as a unified approach to guideline development. RECENT FINDINGS: Clinical guidelines on the management of prostate cancer demonstrate major methodological differences. Most notably, considerable discrepancies with regards to the systems used to grade the quality of the evidence and the strength of recommendation exist. The GRADE approach classifies the quality of evidence as high, moderate, low or very low, according to factors that include study design and execution, and the consistency of the results. It subsequently classifies recommendations as strong or weak, according to the balance between benefits and downsides and the degree of confidence in estimates of the downsides. SUMMARY: There is an urgent need to standardize processes used to develop clinical guidelines for the management of patients with prostate cancer by leading urological organizations. Adoption of the GRADE approach would offer considerable rewards in terms of efficiency, guideline credibility and optimal clinical decision-making.