Position Statement

Evidence-Based Guidelines

This Position Statement was developed as an educational tool based on the opinion of the authors. It is not a product of a systematic review. Readers are encouraged to consider the information presented and reach their own conclusions.

Patients “should be able to count on receiving the care that meets their needs and is based on the best scientific knowledge. Yet there is strong evidence that this frequently is not the case.”¹ The Institute of Medicine’s 2001 Report “Crossing the Quality Chasm” clearly identifies that there is a gap between knowledge and practice.

The American Academy of Orthopaedic Surgeons (AAOS) believes that closing the gap between knowledge and practice will improve clinical performance and the quality of care.

Overview and History

Driven to improve the quality of care and reduce disparities, many organizations, including the AAOS, have turned to the development of clinical practice guidelines. The terms practice guidelines, treatment guidelines, and practice parameters are often used interchangeably and are basically defined as tools to assist practitioners in the diagnosis and treatment of patients. Although practice guidelines have existed in many difference forms for decades, they have often generated conflict and controversy. The proliferation of single-authored, expert, and/or consensus-based guidelines in the 1990’s left many physicians fearing that “cookbook” medicine was being pushed upon them by outside influences including governmental agencies and insurance plans. Furthermore, because guidelines were opinion-based, recommendations often conflicted leaving surgeons uncertain how to practice. In the late 1990’s, proponents of “evidence-base medicine” began to educate guideline developers about the importance of the evidence-base serving as the cornerstone for good clinical decision-making and good patient care, thus highlighting the importance of creating evidence-based guidelines.

Attributes of Evidence-Based Guidelines

Evidence-based clinical practice guidelines have three key attributes:

1. Practice questions are defined and decision options and outcomes are explicitly identified.
2. The best evidence about prevention, diagnosis, prognosis, therapy, harm, and cost-effectiveness is explicitly identified, appraised and summarized in ways that are most relevant to decision-makers.
3. Decision points are explicitly identified where this valid evidence needs to be integrated with individual clinical experience and patient values in deciding on a course of action.

The AAOS is committed to ensuring that guidelines used in the care of orthopaedic patients are based on the best research evidence available.

The Role of the Evidence Base

The foundation for the best clinical practice of medicine evolves from the published, peer-reviewed evidence. Yet the sheer volume of this information presents an almost insurmountable problem to the practicing surgeon. A recently published article indicated that a total of 26,945 papers were published between 1991 and 2000 in the top seven peer-reviewed medical journals alone.² Obviously, no one individual can be aware of all that is being published. Compounding the problem is the variability in experimental quality and the often-contradictory results the literature presents to the practicing surgeon. All articles give data, but the validity of those data are dependent on the experimental methods. The evidence is stronger and therefore more believable in some articles than in others. A relatively small percentage of orthopaedic surgeons are trained to rank the methodological strength. Evidence-based practice guidelines serve to assist the practicing orthopaedic surgeon in his/her quest to improve patient care by consolidating the relevant evidence, and indicating the strength of the recommendation for treatment options.

The Evidence-Base: Implications for New Technologies

Evidence analysis is not only applicable to guideline development, but also to the world of technology assessment. Studies of new technologies should be evaluated as to their levels of evidence, and practitioners should carefully review the evidence and determine the appropriateness of implementing new technologies after a critical assessment of their own surgical skills and their patients’ personal values.

The AAOS believes that the evidence for new technologies must be carefully assessed, encourages all practitioners to objectively evaluate their own surgical skills prior to implementing new technologies.

The Role of Expert Opinions

Broad acceptance of guidelines is always more likely if the process by which the guideline is developed is transparent and explicit. Experts in the evidence-based practice area recognize how difficult it is to develop a guideline when the quality of the literature is not high (e.g., no randomized controlled clinical trials, case control series), and acknowledge that in such instances, expert opinion does play a supplementary role. It is critical, however, that it be explicitly delineated at the outset how expert opinion is to be weighed and utilized in the absence of high quality evidence. The limitations of evidence-based medicine need to be recognized. There will always be topics that are not amenable to evaluation by an evidence-based approach. Expert consensus may be required to complement an evidenced-based conclusion. Consensus should be reached using a Delphi method or other formal structured methodology.

Evidence-Based Guidelines and Implementation of Evidence-Based Practice

Evidence-based practice, as defined by Sackett³ consists of “the integration of best research evidence with clinical expertise and patient values.” Evidence-based practice guidelines represent a logical progression through the diagnosis and treatment of a clinical problem based on the most current evidence that has been evaluated as to levels of evidence. The guideline should represent a reasonable approach to the problem that allows for a wide variance in practice style based on the practitioner’s clinical expertise and experience, as well as the values and preferences of the patient.

Evidence-based practice guidelines are not intended to represent a standard of care or an invariant approach to patient treatment. Furthermore, guidelines should not represent some special interest group’s standard on how diagnosis and treatment should be administered to achieve anything other than the best possible patient care.

With the current trend toward developing physician performance measures for quality improvement and accountability, it must be remembered that evidence-based performance measures can only be derived from evidence-based guidelines. The AAOS supports the development of evidence-based practice guidelines by the Academy and other organizations, and encourages the implementation of evidence-based guidelines by regulatory and accrediting agencies to improve physician performance and ensure the quality of care for orthopaedic patients.

The AAOS believes that implementation of evidence-based guidelines will result in improved quality of care for patients by reducing over-and under-utilization of diagnostic tests and treatment modalities.

Conclusion

Practice guidelines bring order out of chaos. They allow the practitioner to develop treatment for a specific patient based not only on his/her experience and personal knowledge, but also on the most up-to-date scientific evidence, recently reviewed and evaluated as to the strength of this evidence. Through the process of guideline development, experts evaluate and distill the universe of information on a clinical problem down to a usable set of parameters to which the physician can apply his/her own experience and knowledge in managing a patient. Guidelines are not a substitute for continued study, but rather represent a focus for the practitioner to provide the best care for his/her patients. Practice guidelines also serve as an excellent reference source for the physician and can function as an educational tool for the patient.

The AAOS will work with a broad range of public and private agencies, including governmental agencies, medical professionals and others, to ensure implementation of evidence-based practice to improve the quality of care for orthopaedic patients.

References:

1. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. National Academy Press, 2001.
2. Rahman M, Pukui T. A decline in the U.S. Share of Research articles. N Engl J Med 2002: 347:1211-2
3. Sackett DL, Straus SE, Richardson WS, et al. Evidence-based medicine. How to practice and teach EBM, 2nd ed. London: Churchill Livingstone, 2000.

©October 2004. Revised February 2005 American Academy of Orthopaedic Surgeons
This material may not be modified without the express written permission of the American Academy of Orthopaedic Surgeons®.

Position Statement 1163

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