Intended for healthcare professionals

Letters Treatment burden of clinical guidelines

Including practical issues and patient perspectives in Rapid Recommendations

BMJ 2018; 363 doi: (Published 20 November 2018) Cite this as: BMJ 2018;363:k4871
  1. Anja Fog Heen, physician1,
  2. Per Olav Vandvik, physician and methodologist2,
  3. Thomas Agoritsas, physician and methodologist3
  4. On behalf of the MAGIC research and innovation programme
  1. 1Department of Medicine, Innlandet Hospital Trust-division, Kyrre Grepps gate 11, 2819 Gjøvik, Norway
  2. 2Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
  3. 3University Hospitals of Geneva, Geneva, Switzerland
  1. anjaheen{at}

Treatment burden is an often ignored but crucial element in guidelines and clinical decision making.1 We would like to point out some recent advances.

Treatment burden could be appraised in a broader framework of “practical issues” related to how a treatment or test will affect a patient’s daily life. These include issues related to drug routine, the need for subsequent tests, coordination of care, and the implications of decisions on social activities, work, and travel. Clinicians need to raise these topics with patients to find out what is best for each person, ideally through shared decision making.

To do so, guidelines and evidence summaries should systematically include practical issues. Our team in the non-profit MAGIC research and innovation programme ( has developed a publication platform ( that enables organisations to easily add practical issues to their evidence summaries, recommendations, and decision aids.2 We are preparing a manuscript on how we developed the new framework and tools.

As our work with The BMJ on Rapid Recommendations shows,3 guideline panels can explicitly take practical issues into account and provide them to clinicians and patients to support their decisions. The experience has been educational, with examples of direct effects on the recommendations. The panels also use new sources of evidence, such as We have partnered with patients to systematically include their perspectives. This information is incorporated in our SHARE-IT decision aids,4 accessible in MAGICapp through each Rapid Recommendation.

This is an emerging field that will require more research. Another question is how to include practical issues throughout the evidence ecosystem, not only in guidelines, but also in systematic reviews.


  • Competing interests: POV and TA are unpaid board members in the non-profit MAGIC Foundation. AFH conducts her PhD project on practical issues in the SHARE-IT project. No financial conflicts of interests reported.

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