Since the completion of the first AAOS Clinical Practice Guideline (CPG) in 2007, the AAOS department of research and scientific affairs, in conjunction with the Guidelines Oversight Committee, has implemented a detailed guideline development process. This process requires substantial input from AAOS member volunteers. As shown in Fig. 1, the opportunities for member involvement occur at various points in the process (in dark tinted boxes).
The first eight steps in the process focus on development of CPGs. From the very beginning, the CPG unit in the AAOS department of research and scientific affairs depends on member input. It is members who nominate topics for CPG development (Step 1).
Members are welcome to visit the AAOS CPG website (www.aaos.org/guidelines) and encouraged to submit topics for CPGs that they believe would be valuable to the orthopaedic community. The Evidence-Based Practice Committee (EBPC) reviews the topics suggested by members and selects one as the next topic for a CPG (Step 2).
Members are also integral to the work group that develops the CPG. The EBPC solicits workgroup participants with announcements in AAOS Headline News Now, AAOS Now, the Board of Specialty Societies/Board of Councilors (BOS/BOC) electronic Bulletin newsletter, and on the AAOS website. The committee also contacts and requests volunteers from specialty societies that have a vested interest in the specific topic (Step 3).
All AAOS volunteers complete disclosure statements, which are updated semiannually and maintained in the AAOS Orthopaedic Disclosure Program. The AAOS Board of Directors and Committee on Outside Interests have established specific conflict-of-interest standards for guideline work groups, which are intended to minimize the perception of bias and ensure the integrity of AAOS CPGs. Following assessment of conflicts of interest, the EBPC appoints the chair, co-chair and members of the work group (Step 4).
The introductory, face-to-face meeting of the work group is held at AAOS headquarters in Rosemont, Ill. At this meeting, workgroup members begin to formulate the questions for the guideline, set the inclusion criteria, and suggest other orthopaedic or related societies that should later be solicited for peer review (Step 5).
The EBPC is exploring ways that relevant groups can provide input for formulating questions for the guideline, although the final decisions will remain with the work group.
After the guideline framework is established, AAOS staff reviews the available literature and appraises the quality of the studies (Step 6). During a teleconference, workgroup members are asked to approve the included articles, quality appraisals, and evidence tables (Step 7). Approximately 6 weeks after the call, a final face-to-face meeting is held. At this time, the work group develops the CPG recommendations and assigns a grade or rating for each recommendation, based on the evidence (Step 8).
The review process
Following the final meeting of the work group, a draft guideline is produced and enters the review process. As the CPG enters the final stages of development, staff solicits the predetermined societies for peer reviewers. Each society nominates several members, who receive a confidential copy of the draft and provide reviews (Step 9).
Following the review period, the work group revises the draft as needed (Step 10). A second review process, known as the Public Comment period, enables the membership of the AAOS as well as members of the BOC, BOS, and AAOS Board of Directors an opportunity to review the draft document (Step 11). The work group then reviews these comments and compiles the final guideline document (Step 12).
Approval and dissemination
After the final guideline is reviewed and approved by all levels of AAOS leadership (Step 13), the department of research and scientific affairs begins the dissemination process (Setp 14). The AAOS issues an official press release announcing approval of the guideline by the board of directors, and an announcement to the fellowship is made through AAOS Headline News Now. The guideline is also posted to the AAOS website (www.aaos.org/guidelines), the National Guidelines Clearinghouse (www.guideline.gov), and the Guidelines International Network (www.g-i-n.net). Guideline summary articles are published in the following publications:
- Journal of the AAOS
- AAOS Now
- The Journal of Bone and Joint Surgery
The guidelines are also used to develop questions for the Orthopaedic In-Training Examination and are the subject of educational webinars. Guidelines also provide content for Orthopaedic Learning Center courses, and informative displays are build around them at the AAOS Annual Meeting.
For more information about AAOS CPGs, including frequently asked questions, guideline development procedures and processes, and AAOS-endorsement of externally produced guidelines, visit www.aaos.org/guidelines
Kaitlyn Sevarino is the administrative coordinator in the AAOS department of research & scientific affairs.