AAOS’ clinical practice guideline (CPG) project has been ongoing since the release of “Diagnosis and Treatment of Acute Achilles Tendon Rupture” and “Treatment of Distal Radius Fractures” in 2009. As AAOS has gained experience with the process, the guidelines have become more relevant and impactful. In addition, the guideline methodology has become more robust to avoid bias and ensure that recommendations are based on the concept of best available evidence.

The guidelines provide a systematic approach to evidence review, a task most clinicians do not have the time or experience to do on their own.

The problem

Although orthopaedic surgeons are familiar with the role of evidence-based medicine (EBM) in guiding practice decisions, it remains clear that clinical adoption of the best evidence into practice drastically lags behind scientific discovery. It is estimated that it takes almost 10 years for evidence-based recommendations to be adopted into routine practice. Although CPGs are formulated and structured to make adoption of EBM into practice easier for clinicians, many are slow to adopt the guidelines as well.

Guideline recommendations have the potential to improve patients’ outcomes, reduce costs, and significantly decrease variability in care, yet they are inconsistently employed in favor of personal experience and anecdotal evidence, which are resistant to change. In addition, lack of guideline adoption into clinical practice is a barrier to realizing the optimal benefits from our considerable societal investment in medical research. Presently, the United States invests more than $182 billion annually in medical research from public and private sources, the vast majority of which come from industry. CPGs analyze the summation of that research, using the concept of best evidence synthesis to make clinical recommendations that can improve the quality of our care.

The largest barrier to adoption of EBM and CPG recommendations lies in entrenched clinician attitudes and behaviors. The easiest way to increase the influence of EBM is to utilize CPGs in the education of orthopaedic surgery residents. When residents are familiar with the CPGs and rely on them as trusted sources to guide clinical treatment decisions, they will become standard for future practice. In addition, faculty mentors must embrace the change as well. A better understanding of the methodology of CPGs is essential to developing trust in the recommendations.

CPG methodology

All AAOS guidelines are created with strict methodology and inclusion criteria. The concept of best evidence synthesis is critical to allow physicians to come to the right conclusions based on available research, which often can be the opposite of the conclusions that could be made from the most readily available study, if we are not careful.

As we increasingly rely on computers and the internet to guide treatment, we become increasingly susceptible to predatory publications. There has been an explosion of research publications that are all available online, and many are not peer reviewed or scientifically vetted. Often, the lowest-quality research is the easiest to find. The danger of doing a “literature search” to investigate a topic or using limited, select evidence to support a preferred method of treatment based on experience or training bias is that, although supporting evidence may be identified, without review of all evidence—and the best evidence—erroneous conclusions can be made. The concept of use of best evidence is essential to the EBM process, and most guidelines are developed through a review of several thousand articles, all of which are graded in relation to specific outcomes, to result in the best evidence. This process is both time and labor intensive and not reproducible through a quick literature search.

With the prevalence of conflicts of interest in research, which often are not transparent, and the easy availability of low-quality studies that often lack peer review, CPGs are more important now than ever in helping clinicians identify best practices.

Accessing AAOS CPGs

With this in mind, OrthoGuidelines is a trusted orthopaedic resource; it is a mobile app that offers easy access to these guidelines. On the app, users can access different CPGs through keyword searches and sort by strength of recommendation, stage of care, and specialty. The app also houses all AAOS appropriate use criteria (AUCs), which are derivative products that incorporate expert opinion to guide clinical treatment decisions to fill in gaps where evidence is lacking. AUCs grade treatment options into the categories always, sometimes, or rarely appropriate. In addition to AUCs, other implementation resources, such as clinician checklists, impactful statements, and clinical practice plain language summaries, are also available to assist clinicians in their decision-making efforts. The mobile app is free and available on your desktop browser or as a native app from Apple’s iOS and Google Play. Finally, work has been done to create clinical pathways based on CPGs to improve clinical utility and drive standard work to decrease variability in patient care and improve quality.

To assist with educational efforts, the AAOS quality website now contains a slide deck for each CPG. The slide decks are open domain, and AAOS encourages their use for grand rounds lectures, conferences, and other educational forums. Each deck details the methodology utilized in constructing a CPG from start to finish, an overview of the specified guideline, all guideline recommendations (including the rationale and potential risks and harms), and future research associated with each recommendation. Each slide deck includes a clinical case study for discussion to further facilitate education. The slides are free for use, and users can modify the presentation length by removing or combining slides to fit their personal needs. Visit www.aaos.org/qualityprograms for more information.

Karl C. Roberts, MD, FAAOS, is the program director for the Michigan State University–Spectrum Health Orthopedic Surgery Residency Program, and he serves as CPG section leader for the AAOS Evidence-based Quality and Value Committee.

Reference 

1. Green LW, Ottoson JM, García C, et al: Diffusion theory and knowledge dissemination, utilization, and integration in public health. Annu Rev Public Health 2009;30:151-74.