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AAOS Now

Published 10/1/2008
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Fareeha Shuttari-Khan, MPH

Improving quality of care—one guideline at a time

A year’s effort pays off for patients and practitioners

First identified more than 150 years ago, carpal tunnel syndrome (CTS) is one of the most commonly diagnosed and treated entrapment neuropathies. CTS is estimated to affect up to 10 percent of the entire population. With the variety of tests and treatment options used for this condition, it’s no wonder that developing evidence-based clinical practice guidelines (CPGs) for CTS was high on the AAOS agenda.

More than a year ago (May 2007), the AAOS Board of Directors approved evidence-based CPGs on the diagnosis of CTS. Since then, a workgroup, chaired by Michael W. Keith, MD, has been developing follow-up guidelines on the treatment of CTS. Their efforts have now been finalized, approved, and posted at www.aaos.org/guidelines

Countless hours, innumerable e-mails
Workgroup members devoted countless hours—including several conference calls and two in-person meetings—and shared innumerable e-mails in developing the CTS treatment CPGs. The guideline development process is designed to eliminate bias, remain systematic, and foster transparency.

The development process began with an introductory in-person meeting to review the process with members of the Workgroup and to formulate “simulated recommendations.” These recommendations defined the scope of the CPG and guided the literature searchers.

Once the literature search was completed, members of the work- group and staff in the guideline unit of the AAOS research department performed a systematic review of the relevant literature. Details of the systematic review and all references reviewed are documented in the final CPG.

The document was drafted and the workgroup met again, in December 2007, to review and develop its final recommendations. Then the document was distributed to outside specialty review panels and to a select group of other individuals for public comment. As these comments are received, members of the work- group review and address them before proceeding through the AAOS approval process with a final document.

Within the Academy, members of the CPG Workgroup, the Guidelines and Technology Oversight Committee, the Evidence-Based Practice Committee, and the Council on Research, Quality Assessment and Technology (CORQAT) all had opportunities to review the document before it was presented to the Board of Directors for final approval.

Valuable on several levels
According to Kristy L. Weber, MD, CORQAT chair, the guidelines deliver value on several levels. She pointed to the current trend to improve healthcare quality and delivery through the use of guidelines and performance measures, noting that AAOS’ efforts could become the basis for pay-for-performance measures being developed by the Centers for Medicare and Medicaid Services.

“Evidence-based guidelines on carpal tunnel syndrome, in particular, were needed,” she said, “and could influence decisions on workers’ compensation issues, as well as hospital and payor guidelines.

“It may seem that these guidelines take a long time to develop—and they do,” she continued. “The AAOS system is thorough, and twice as fast as other organizations.” According to Dr. Weber, other organizations take 18 to 36 months to develop a guideline, compared to the 12 to 18 months that it takes the AAOS develop a CPG.

An enriching experience
According to Kevin Chung, MD, a plastic surgeon and member of the American Society for Surgery of the Hand who served on the work group, “This effort was personally enriching because of the structure and rigor the AAOS process for guideline development requires. The AAOS should be commended for devoting the necessary energy and resources to develop much-needed scientific support for applying clinical recommendations to patients. This CPG will have a great impact because hundreds of thousands of surgeries are performed each year to treat carpal tunnel syndrome.”

Fareeha Shuttari-Khan, MPH, is the evidence-based medicine coordinator in the AAOS research department. She can be reached at shuttari@aaos.org