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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Maybe we need a critical appraisal tool to read guidelines
- Alejandro Piscoya (30 November 2008)
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Clinicians facing conflicting recommendations: Use commonsense?
- Felix ID Konotey-Ahulu (5 December 2008)
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L’Allegro and Il Penseroso (Milton)
- Hugh Mann (6 December 2008)
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One must often act in the absence of certainty
- M K Lee (8 December 2008)
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"Invalid" recommendations: do they exist?
- Joseph C Watine (15 December 2008)
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Invalid recommendations do exist
- Jan Matthys (4 January 2009)
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Guidelines are only guidelines
- Daniel McQueen, Paul St. John Smith, Consultant in General Adult (Assertive Outreach) and Community Psychiatry, Cranbourne Center, Mutton Lane, Potters Bar, Herts, EN5 4AA (26 January 2009)
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Judging guidelines
- Joan McClusky (29 January 2009)
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Appraising clinical guidelines_an important omission
- Françoise Cluzeau, (on behalf of the AGREE Research Trust) (29 January 2009)
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Authors response
- Paul Glasziou, Andy Oxman, John Williams (23 February 2009)
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Conflicting recommendations
- Jan H. Matthys, Marc De Meyere, Prof. em. of General Practice (4 March 2009)
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Alejandro Piscoya, Professor of Medicine Universidad Peruana de Ciencias Aplicadas - UPC
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This is quite an important issue that is currently being discussed around the world and has led to very strong tools like the GRADE criteria that attempts to unify the different levels of evidence that are used or the ADAPTE group work on developing new guidelines by adapting the ones previously developed around the world making the necessary changes in order to make it work in another settings. However I feel that even though there are several tools developed by CASP to help us appraise different types of articles like RCT, economic evaluations and even systematic reviews (that are the basis for guidelines), we may need one specific tool to learn to read a guideline and recognize whether its quality is good and also understand the differences among guidelines. A great start is this editorial and the questions it proposes. Competing interests: None declared |
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Felix ID Konotey-Ahulu, Kwegyir Aggrey Distinguished Professor of Human Genetics, University of Cape Coast, Ghana Consultant Physician Genetic Counsellor in Haemoglobinopathies, 10 Harley Street, London W1G 9PF
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Clinicians facing conflicting recommendations: Use commonsense? It is difficult to imagine something that this excellent editorial by Andrew Oxman, Paul Glasziou, and John Williams has not covered [1]. As the authors have shown, guide lines vary from country to country. Even when in the same country ample evidence exists that the guide lines are causing harm, nay death, (vide NCEPOD Report on deaths from opiods given to patients in sickle cell crisis) [2], experts are found defending the guide lines (vide Professor of Haematology on BBC TV Thursday 13 November 2008). Though clinicians may acquire what Alejandro Piscoya calls “a critical appraisal tool to read guide lines” [3] there will be no lack of experts with contrary views. Diamorphine is banned in the USA for sickle cell disease [4] but because the drug features in the UK Guide lines it is used even for those who have never before had it in their countries of origin (in the West Indies or in West Africa) [5]. But those who approve of its use here also trained in the same top class UK universities where I trained (London, Liverpool, Cambridge) and are also Fellows of the same Royal Colleges of Physicians that I also belong to (Glasgow and London). Therefore, excellent medical training appears to have little to do with decision to adhere to one particular set of guide lines or other. It seems to me that the British Consultant Clinicians (and there are quite a few) who ignore Guide lines in this respect, do so on common sense grounds. One of the problems arising from this “ignore the guide lines on common sense grounds” attitude is when the junior doctors understudying them move away to work with other consultants who are equally qualified, but who hold contrary views. If in the practice of different consultants ‘”conflicting” guide lines do not result in any harm (at Westminster Hospital, on the same firm, Dr J C Gavey taught us to use Digitalis leaf while Dr Richard Bayliss used Digoxin tablets for their patients with equal benefit) then no problem arises, but when “Guide lines” result in patient death in significant numbers then, surely, is appeal to common sense not called for? Felix I D Konotey-Ahulu MD(Lond) FRCP(Glasg) FRCP(Lond) DTMH(L’pool)
FGCP
1 Oxman A D, Glasziou P, Williams Jr J W. What should clinicians do when faced with conflicting recommendations? BMJ 2008; 337:a2530 http://www.bmj.com/cgi/content/full/337/nov28_2/a2530 2 NCEPOD. A Sickle Crisis? A Report of the National Confidential Enquiry into Patient Outcome and Death, 2008. [S B Lucas, Clinical Coordinator; D G Mason, Clinical Coordinator; M Mason, Chief Executive; D Weyman, Researcher; Tom Treasurer, NCEPOD Chairman] info@ncepod.org.uk 83 pages. 3 Piscoya Allejandro. Maybe we need a critical appraisal tool to read guide lines. BMJ Rapid Response 28 Nov 2008. http://www.bmj.com/cgi/eletters/337/nov28_2/a2530#205445 4 Ballas SK. Sickle Cell Pain. IASP Press, Seattle 1998, page 58 5 Konotey-Ahulu FID. Poor care for sickle cell disease patients: This wake up call is overdue. BMJ Rapid Response 28 May 2008. http://www.bmj.com/cgi/eletters/336/7654/1152-a#196224 Competing interests: None declared |
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Hugh Mann, Physician Eagle Rock, MO 65641 USA
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Life is a series of dilemmas. We are constantly faced with imperfect choices which conflict with each other. How can we resolve such dilemmas? First, we must recognize that both choices might be wrong, and that we have yet to consider the correct choice. So we must not rush headlong into prematurely resolving a dilemma by making a choice. Instead, we must delineate and analyze the underlying factors and search for all possible solutions. Let’s strive to be more penseroso (thoughtful) and less allegro (action-oriented). Competing interests: None declared |
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M K Lee, Consultant Neurologist Sunway Medical Centre, 46150
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Dear Sir I am moved to respond to this topic because it seems to me that the medical profession is now deemed unable to make rational choices in situations where there are no certain answers, the so-called "evidence- free zone". We are now apparently shackled to evidence-based medicine. How else have we been guided in the past except by the EBM of the day? There is no way any CPG can address the infinite permutations which may present themselves to doctors. Therefore, it behoves each of us, as trained professionals, to use our best judgment, and if necessary, to act against an "evidence-based recommendation" should the situation require it. We do not see politicians or economists wring their hands in inaction during the current sub-prime meltdown. They act, as entrusted by the electorate, taking into account the best advice of the day. We can only be judged ultimately by our bona fide intentions; this is the standard expected by the highest courts. There are no guarantees in life - even patients can accept this. Competing interests: None declared |
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Joseph C Watine, consultant, laboratory medicine hôpital de Rodez, France
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the first sentences of this editorial sounded quite promising to me however, I was quite disappointed in the end, mainly for 2 reasons: 1) nowhere in this text do I read what seems to be the most important and obvious thing for clinicians to do when faced with conflicting recommendations, ie: in this sort of situation patients may particularly need to be informed so that they can really share the final informed decision 2) in the first sentences of this editorial, the authors indicate that recommendations can conflict for "valid" reasons, or for "invalid" reasons. This is fine. The problem is that they only discuss in detail one example of conflicting recommendations (ie: sore throat recommendations) and, back luck for the readers, in this example, the conflicting recommendations happen to be all equally valid in the end. Weren't the excellent experts who co-author this most excellent editorial able to find at least one example of "invalid" recommendation? And if such excellent experts weren't, how could busy lay-clinicians expect to find such examples themselves? Would the authors be so kind as to provide us with a few examples of recently published "invalid" recommendations, preferably co-authored by governmental organizations? Unless it would not be politically correc for the authors to do so? Please consider my comments above as positive comments. Competing interests: None declared |
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Jan Matthys, GP 9000 Ghent, Belgium
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Joseph C Watine writes that nobody seems to know what to do when faced with conflicting recommendations. As one of the authors of the Belgian guideline of acute sore throat I suggest to look at the evidence used: for example two North American and the Canadian guidelines do not refer to the three relevant European randomised placebo controlled clinical trials (penicillin versus placebo). The North American guidelines do not cite the Cochrane review, though Cochrane reviews may be among one of the most relevant sources of evidence. The Finnish guideline cites only 5 references, the acute sore throat guideline of the Netherlands cites 85 references including all relevant European and American trials, the Cochrane and other systematic reviews. We agree with Watine that comparing evidence is not always obvious for the busy lay-clinician, but arguing that conflicting recommendations happen to be all equally valid in the end (after comparing a guideline with 5 and one with 85 references) is not fully exact. Competing interests: co-author Belgian guideline of acute sore throat |
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Daniel McQueen, Specialist Registrar in Psychotherapy (Psychiatry) Cassel Hospital, 1 Ham Common, Richmond, London, TW10 7JF, Paul St. John Smith, Consultant in General Adult (Assertive Outreach) and Community Psychiatry, Cranbourne Center, Mutton Lane, Potters Bar, Herts, EN5 4AA
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It should come as no surprise that different guidelines differ or even contradict each other. A number of points should be further emphasized: 1) Guidelines are just that, not rules, or complete statements of
knowledge.
Higgins MP; Tully MP; 2005. Hospital doctors and their schemas about appropriate prescribing. Medical Education, Feb; 39 (2): 184-93 Norman G; Eva K; Brooks L; Hamstra S; 2006. Expertise in medicine and surgery. In; The Cambridge Handbook of Expertise and Expert Performance. Eds Ericsson KA; Charness N; Feltovich PJ; Hoffman RR; Cambridge University Press. pp339-353 Competing interests: None declared |
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Joan McClusky, Medical writer New York, NY 10003
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Regarding the development and use of conflicting guidelines, perhaps it is time to develop a standardized document for their development that includes the following: 1. Which group--individuals, association, etc--called for the development
of
the guidelines?
There should also perhaps be a centralized repository for all treatment guidelines with an area for public/professional comment before they are published. Competing interests: None declared |
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Françoise Cluzeau, Lecturer St George's University of London, UK, (on behalf of the AGREE Research Trust)
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We agree with Oxman and colleagues that clinicians should have criteria to determine if a guideline has been developed systematically and transparently. However, we are surprised that they did not mention the Appraisal of Guidelines Research and Evaluation (AGREE) Instrument[1]. The AGREE instrument was developed by an international collaboration of researchers and guideline developers and was validated on 100 guidelines from 11 countries[2].It is recognised as the gold standard for assessing the quality of clinical guidelines. It has been translated in 20 languages. It is used by many guidelines developers around the world and has been quoted in many peer reviewed articles. Therefore, we do not think that a new critical appraisal tool for guidelines is needed, as suggested by Alejandro Piscoya. Instead we suggest researchers continue to improve the AGREE Instrument and build on its existing foundations such as that by the AGREE Next Steps Collaboration. This consortium has been established to improve the measurement properties of the instrument to help clinicians to better discriminate between valid and invalid recommendations. 1.www.agreetrust.org. Accessed 28 January 2009. 2.The AGREE Collaboration. Development and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: the AGREE project. Quality and Safety in Health Care 2003; 12(1): 18-23. Competing interests: Francoise Cluzeau is the chair of the AGREE Research Trust |
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Paul Glasziou, Professor of Evidence-Based Medicine University of Oxford, OX3 7LF, Andy Oxman, John Williams
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Our editorial dealt with conflicts in a specific recommendation, not whole guidelines. However, we agree that critical appraisal of guidelines would be helpful, but is problematic. A full guideline may make statements or recommendations on dozens of issues: some may be strongly based on evidence and others not. Hence, the best we can do for a whole guideline document is to say we trust the process and people, which will require they lay out clearly the evidential and practical justification for recommendations. While the AGREE tool is useful for teaching guideline developers what they should do, it is impractical in day to day clinical practice, as it is too long and does not reach a conclusion about whether trust is warranted. Like Dr Watine, we would like to see a list of invalid recommendations. But some that spring to mind are guideline recommendations for HRT prior to the Women's Health Initiative Study, guidelines recommending blood glucose self monitoring in type II diabetes (discredited by DiGEM and other trials), and guidelines that pushed HbA1c targets ever lower (brought into questioned by several large trials published last year). We are sure many others can be added to this list, including some of the recommendations in the contradictory recommendations referenced in our editorial. Finally, we agree with Lee and McQueen that good clinical decision making involves more than simple usage of a guideline. Professionalism should, among other things, include a sufficiently deep enough understanding of the basis of recommendations that it enables the clinician to know when to adapt or ignore guidelines in individual patients. Competing interests: We are the authors of the editorial. |
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Jan H. Matthys, General Practitioner Department of General Practice and Primary Health Care, University of Ghent, UZ, Ghent, Belgium, Marc De Meyere, Prof. em. of General Practice
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Dear, Contrary to F. Cluzeau (1), we were not very surprised that A. Oxman (2) and colleagues did not mention the appraisal of guidelines research and evaluation (AGREE) instrument. The main reason is that the scoring system does not differentiate between items. In our comparison of the 10 available national internet guidelines on acute sore throat (3), we decided not to use the AGREE scores as assessed by a panel from five different countries and with four of them familiar with the AGREE collaboration. We did not use it because surprisingly, three of the 10 guidelines - two North-American and the Canadian guidelines- had higher AGREE scores than most other guidelines, despite the fact that the three guidelines did not cite one of the different European trials nor the Cochrane review. Further evaluation of the AGREE instrument showed that only three items - on a total of 23- assesses the description of the evidence, whereas each item has the same weight. The result is that high AGREE scores do not guarantee that the selection of the evidence has been adequately performed and that different items may have different relevance to the validity of the recommendations.(4) Concerning the acute sore throat guidelines, which are frequently mentioned in the article of A. Oxman, (2) it seems that rationalization of historical based practice e.g. value placed to prevent rare complications such as acute rheumatic fever, acute glomerulonephritis, or culture of investigation.. plays an important role. We can suppose that most guideline developers may be aware and may even mention the available evidence (3), but sometimes they prefer not to use these in their recommendations because in their country different values exist about baseline risks e.g. baseline risk for acute rheumatic fever in an acute sore throat, even with the awareness that the incidence of acute rheumatic fever is very low in developed countries. We agree with Cluzeau that the AGREE instrument remains one of the golden standards for the development process of guidelines and that it needs further improvement of its measurement properties. Other items, such as ‘monitoring recommendations’ in clinical practice guidelines e.g. exercise tolerance, hospital admission, side effects of treatment, periodic function tests, quality of life… may be very useful in periodic assessments that guide the management of a chronic or recurrent disease but are actually not covered in the AGREE instrument. (5) Besides AGREE, the World Health Organization (WHO), and other organizations around the world, have also recognized the need to use more rigorous processes to ensure that health care recommendations are informed by the best available research evidence (6) Dr. Jan Matthys, Department of General Practice and Primary Health Care, University of Ghent, UZ, De Pintelaan 185, 9000 Gent, email: jan.matthys@ugent.be 3312 Prof. em. Marc De Meyere, Department of General Practice and Primary Health Care, University of Ghent, UZ, De Pintelaan 185, 9000 Gent, email: marc.demeyere@ugent.be 1. Cluzeau F. AGREE Research Trust. Let's not forget AGREE. BMJ. 2009;338:b407. 2. Oxman AD, Glasziou P, Williams JW, Jr. What should clinicians do when faced with conflicting recommendations? BMJ. 2008;337:a2530. 3. Matthys J, De Meyere M, van Driel ML, De Sutter A. Differences Among International pharyngitis Guidelines: Not Just Academic. Ann Fam Med. 2007;5:436-443. Review. 4. Grilli R, Magrini N, Penna A, Mura G, Liberati A. Practice guidelines developed by specialty societies: the need for a critical appraisal. Lancet. 2000;355:103-6. 5. van den Bemt L, Schermer T, Smeele I, Bischoff E, Jacobs A, Grol R, van Weel C. Monitoring of patients with COPD: a review of current guidelines' recommendations. Respir Med. 2008;102:633-41. Review. 6. Schünemann HJ, Fretheim A, Oxman AD. Improving the use of research evidence in guideline development. Guidelines for guidelines. WHO Advisory Committee on Health Research. Health Res Policy Syst. 2006 November & December. Competing interests: Jan Matthys and Marc De Meyere are the Belgian authors of the acute sore throat guideline |
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