We thank Khan et al for their interest in our article assessing practice guidelines in interventional medical specialties
1
and strongly agree that the issues with guidelines go beyond just those of the interventional subspecialties. In fact, we have already reported the results of other studies citing the limited evidence among gastroenterology2
and inflammatory bowel disease3
guidelines, and others have shown similar results for cardiology,4
infectious diseases,5
and liver diseases.6
We believe that considerable improvements can be made in the quality of contemporary guidelines, beginning with the makeup and conduct of guideline development committees, in which much of the guidelines’ strengths are rooted.
7
A key aspect of establishing a guideline is the degree of transparency mandated throughout the development process. How the committee deals with potential conflicts of interest, who is chosen to participate in the committee, how the evidence is researched, and how the recommendations are formulated all must be determined before starting the guideline development process. All of these standards are determined by the guideline development committee.7
As we stated in our article,
1
we agree with Khan et al that the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) system is an easier system for the reader to understand and has the additional benefit of highlighting areas in need of further research. However, although we agree that the professional societies have done a great service in the development of practice guidelines, when statements based on poor evidence are published, there is a potential for harm. For example, guidelines based only on expert opinion are oftentimes perceived (eg, by insurance companies and in malpractice cases) as an irrefutable standard of care to which clinicians should be held accountable. Instead of relying so heavily on expert opinion guidelines, we suggest, as we have in our previous publications, that a “best practice statement” be used instead of a guideline when quality evidence in not available.2
, 3
A best practice statement would complement the GRADE system, indicating that evidence is lacking and that the recommendations are based on expert opinion. However, it is likely that as research is reported over time, an evidence-based standard of care may be established. Until that time, though, expert opinions should be viewed with circumspection when used as a standard for physicians’ actions (eg, in malpractice cases or in quality assessments).Ultimately, we commend Khan et al for further highlighting the important work that still needs to be done to improve current practice guidelines.
References
- Systematic analysis underlying the quality of the scientific evidence and conflicts of interest in interventional medicine subspecialty guidelines.Mayo Clin Proc. 2014; 89: 16-24
- Systematic analysis underlying the quality of the scientific evidence and conflicts of interest in gastroenterology practice guidelines.Am J Gastroenterol. 2013; 108: 1686-1693
- Systematic review: the quality of the scientific evidence and conflicts of interest in international inflammatory bowel disease practice guidelines.Aliment Pharmacol Ther. 2013; 37: 937-946
- Conflicts of interest in cardiovascular clinical practice guidelines.Arch Intern Med. 2011; 171: 577-584
- Analysis of overall level of evidence behind Infectious Diseases Society of America practice guidelines.Arch Intern Med. 2011; 171: 18-22
- Assessment of the quality of evidence underlying international guidelines in liver disease.Am J Gastroenterol. 2012; 107: 1276-1282
- Graham R. Mancher M. Miller Wolman D. Greenfield S. Steinberg E. Clinical Practice Guidelines We Can Trust. National Academies Press, Washington, DC2011
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© 2014 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.
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- Clinical Practice Guidelines: Still Miles to Go…Mayo Clinic ProceedingsVol. 89Issue 6
- PreviewIn their article published in the January 2014 issue of Mayo Clinic Proceedings, Feuerstein et al1 reported that only a relatively small number of the guidelines from interventional subspecialty societies are based on evidence derived from randomized controlled trials. This scenario is not limited to guidelines developed by interventional medicine societies; guidelines developed by other professional organizations are also largely based on low levels of evidence.2-4 This factor is largely related to lack of research focused toward bridging gaps in the evidence base.
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