Improvements lead to stronger, clearer recommendations
In 2006, the AAOS Board of Directors approved the creation of a Clinical Practice Guideline (CPG) program at the Academy. Since then, the AAOS has been developing and publishing CPGs to serve as educational tools for its membership.
The AAOS has allocated resources to the in-house assessment of current published scientific and clinical information, as well as the formation and function of dozens of member volunteer groups.
Over the years, the Committee on Evidence-Based Quality and Value (EBQV) has worked with the AAOS department of research, quality, and scientific affairs to create a better CPG product. As a result, recommendation language has been improved, PICO (Patient, Intervention, Comparison, Outcome) research questions replaced preliminary recommendations, and the creation of OrthoGuidelines, an online and mobile platform, improved accessibility to the guidelines.
CPG volunteer work groups have also grown in size. They now include increased representation from relevant orthopaedic specialty societies and external discipline specialty societies such as physical therapy, infectious disease, and imaging.
These changes in methodology, coupled with a growing literature base, have resulted in stronger recommendations. Whereas searches on earlier guideline topics returned between 1,000 and 7,000 abstracts, the more recent 2014 AAOS CPG on Management of Hip Fractures in the Elderly returned more than 16,000.
While procedural changes have not changed the manner in which recommendation strength is determined, the new methodology has resulted in guidelines that encompass the complete episode of care.
For example, newer guidelines include recommendations on preventive care, screening, diagnosis, nonsurgical treatment, surgical treatment, postoperative treatment, and rehabilitation as applicable. These new guidelines offer as many as 25–38 recommendations. In comparison, most early guidelines contained fewer than 12–16 recommendations, and in some cases, only 3–7 recommendations.
Although AAOS is proud to provide a more complete product with this new method of CPG development, questions remain. How many of the 20–40 recommendations are new, groundbreaking, or surprising? How many conflict with previous standards? And how many are simply confirming current practice?
With these questions in mind, the EBQV created a new way to focus on the highlights of each AAOS CPG. Although the OrthoGuidelines online platform and app enable users to sort recommendations by strength (ie, only view strong recommendations, moderate recommendations, etc.), there was no tool to separate recommendations based on their potential impact on orthopaedic surgeons’ daily practice.
In response, the EBQV created Impactful Statements, which call attention to AAOS CPG recommendations that are supported by strong or moderate evidence and diverge most from current practice. This influence can be due to one or more of the following:
- evidence highlighting current variations in care that were previously unsupported by evidence
- current evidence supporting a significant difference or change from current clinical practice or previously held gold standard of care
Impactful recommendations were subsequently rewritten as actionable statements and have since been published on www.orthoguidelines.org. OrthoGuidelines is available to AAOS members and the public, both online and as a free app for iOS and Android devices.
The impactful statements, and other tools derived from AAOS CPGs and Appropriate Use Criteria (AUC), have been published under a new Implementation Resources tab (Fig. 1). This tab is also home to AAOS clinician checklists and will soon house CPG plain language summaries, along with other resources for clinicians and patients, as they become available (Fig. 2).
Articles from the EBQV in upcoming issues of AAOS Now will feature highlights of AAOS Impactful Statements, including how these recommendations can affect current orthopaedic practice.
Kaitlyn S. Sevarino, MBA, is the evidence-based quality and value specialist in the AAOS department of research, quality, and scientific affairs.