Published 9/1/2008
Mark E. Easley, MD

Evidence-based clinical practice guidelines: Progress to date

Two guidelines, one technology overview completed; more to come

The Guidelines and Technology Over­sight Committee (GTOC) was established in 2006 to improve the quality of orthopaedic care by overseeing the development of evidence-based clinical practice guidelines (CPGs) and technology overviews (TOs). The committee also prioritizes topics for development and, with assistance from the Evidence-Based Practice Committee (EBPC), assigns and reviews methodology standards for CPG and TO development.

In addition, the GTOC addresses quality improvement issues raised by various AAOS committees and external clinical quality maintenance organizations. A recent GTOC Task Force headed by Laura L. Tosi, MD, developed a review protocol for the endorsement of external clinical practice guidelines, which was approved by the AAOS Board of Directors at its June 2008 meeting.

Learning from experience
Two evidence-based CPGs and one TO are now complete, and many more are in production. The GTOC closely monitored the trials and tribulations associated with the development of these evidence-based documents and used this information to update the development process. Now GTOC is able to oversee 11 guidelines and two technology overviews in different stages of development.

The first guidelines—Diagnosis of Carpal Tunnel Syndrome (CTS) and Prevention of Symptomatic Pulmonary Embolism (PE) in Patients undergoing Total Hip and Knee Arthroplasty—were approved by the AAOS Board in May 2007. These topics were chosen based on the following considerations:

  • burden of disease
  • unit or aggregate cost of treatment or diagnosis
  • variation in the treatment or diagnosis
  • availability of existing guidelines on the topic
  • availability of sufficient research to support the topic
  • membership input and interest

Any AAOS member can submit topics for consideration, using the form available on the AAOS Web site (www.aaos.org/guidelines). The GTOC will discuss the topics and prioritize them for development.

The GTOC also nominates a chair for each CPG or TO work group; the chair solicits members to join the work group. The AAOS Clinical Practice Guidelines Unit works closely with the work groups throughout the process.

Ongoing efforts
After the Diagnosis of CTS guidelines were completed, a work group chaired by Michael Keith, MD, was formed to develop a CPG on the Treatment of CTS. This CPG will be considered by the AAOS Board at its September meeting.

Additionally, various efforts have been made to educate physicians about the current guidelines and technology overviews, including the recent Webinar about the PE guidelines. The Scientific Exhibit sponsored by the EBPC and GTOC at the 2008 Annual Meeting educated participants about the language used in describing clinical practice guideline recommendations. Early next year, the Journal of the AAOS will publish summary articles on the first two CPG guidelines.

It’s not easy
Although the current CPGs include several meaningful recommendations developed from the best available literature, both work groups acknowledged limitations in evidence. For the CTS diagnosis CPG, for example, work group members noted that “high quality evidence is not readily available for carpal tunnel syndrome diagnosis at this time” and that their “guideline has been hindered by a relative lack of studies of the best design…and specifically hindered by an abundance of case control studies.”

Likewise, the members of the PE work group observed that limitations existed in “large clinical heterogeneity in the interventions” and that “none of the studies [was] designed to investigate PE as a primary outcome.”

Despite these limitations, both sets of guidelines serve as valuable and easily accessible educational resources for physicians and pa­tients alike. The recognition of these limitations should encourage the development of higher-quality research.

The final document of each CPG includes the contact information for the members of the CPG Work Group, the CPG development process, and a complete citation of the literature. In addition to the recommendations, the rationales are included. The completed CPGs are available at www.aaos.org/guidelines.

Mark E. Easley, MD, is a member of the Guidelines and Technology Oversight Committee. For more information about AAOS CPGs or the committee, visit www.aaos.org/guidelines or contact Fareeha Shuttari-Khan at shuttari@aaos.org