Guidelines, AUC, conflicts of interest among topics discussed
AAOS members and staff from the Academy's department of research, quality, and scientific affairs (RQSA) were among the featured participants at the Guidelines International Network (G-I-N) conference this past September in Philadelphia, an event that drew 511 conference delegates from 36 different countries. G-I-N is an international group that aims to advance the field of guideline development and implementation. AAOS staff led one workshop and made four oral presentations and eight poster presentations at the conference.
Under the banner "Individualized Guidelines and Clinical Performance Measurement in an Era of Personalized Medicine," the G-I-N conference was an opportunity to learn about both the current state of guideline development and exciting advances on the horizon.
Sharing the AAOS experience
David S. Jevsevar, MD, MBA, chair of the AAOS Council on Research and Quality, along with Jayson Murray, MA, manager of the evidence-based medicine (EBM) unit, and EBM research analysts Ryan Pezold, MA, and Kyle Mullen, led a workshop on appropriate use criteria (AUC). They discussed the AAOS process for developing AUC and taught attendees how to use the AUC method within their own organizations.
AUCs are created by combining the best available scientific evidence with the collective judgment of clinical experts to create statements regarding the appropriateness of a treatment based on patient-specific medical history, symptoms, and test results. The AAOS has been a leader in the creation of AUC for orthopaedic treatments built on its clinical practice guidelines (CPG).
In her presentation, Deborah Cummins, PhD, director of the AAOS RQSA, discussed what happens when the evidence conflicts with industry interests. She outlined industry push-back to the AAOS CPG on osteoarthritis of the knee, which recommended against the use of intra-articular hyaluronic acid. Noting that although professional associations cannot compete with industry from a funding or marketing perspective, Dr. Cummins pointed to education and leadership as ways that associations can influence best practices. She documented the strategies that industry used to discredit the guideline, as well as how AAOS leadership and staff responded.
In a separate presentation, Dr. Cummins also discussed the development of the OrthoGuidelines website and mobile app. OrthoGuidelines is a mobile, web-based tool that puts CPGs and AUC in the hands of surgeons, for quick and easy reference (www.orthoguidelines.org or downloadable from the Apple or Google Play stores).
Jackie Ryan, MPA, manager of the performance measures unit, presented a case study comparing the AAOS performance measure development process to the recently published G-I-N reporting standards for guideline-based performance measures. The presentation outlined the process and criteria used by AAOS in developing orthopaedic clinical performance measures for the orthopaedic care of low-energy proximal femur fractures. These measures were based on recommendations from the AAOS CPG on Management of Hip Fractures in the Elderly. The analysis showed that the AAOS process included all nine of the G-I-N reporting standards recommendations for guideline-based performance measures.
Finally, Kaitlyn Sevarino, MBA, evidence-based quality and value specialist, summarized how the AAOS incorporates patient values in CPG development. She noted that surveys are used to determine which topics are most important to patients. Survey results are then provided to the physician workgroups developing research questions for the guideline. The inclusion of patient values led to an increase in the number of pain management and risk factor recommendations in AAOS guidelines.
Benefitting from the experience of others
The G-I-N conference provided an opportunity for the AAOS to share its advancements in technology and methodology with guideline developers from other organizations. It also afforded AAOS staff the opportunity to learn from other organizations and guideline developers.
For example, Paul Shekelle, MD, PhD, of the Veterans Affairs Evidence Synthesis Program, discussed developments in the use of machine-learning and text-mining software to accelerate the systematic literature review process. Although use of machine learning is still in its infancy and must be subjected to further validation, it could drastically cut the time necessary to identify relevant literature.
G-I-N Conference Abstracts