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Introducing the Future of ACCP Clinical Practice Guidelines

2012; Elsevier BV; Volume: 141; Issue: 2 Linguagem: Inglês

10.1378/chest.11-2906

1931-3543

Mark L. Metersky, Ian Nathanson,

Antiplatelet Therapy and Cardiovascular Diseases

Accompanying this issue of CHEST, readers will find the supplement containing the Executive Summary,1Guyatt GH Akl EA Crowther M Gutterman DD Schünemann HJ for the Antithrombotic Therapy and Prevention of Thrombosis Panel Executive summary: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines.Chest. 2012; 141: 7S-47SAbstract Full Text Full Text PDF PubMed Scopus (1380) Google Scholar Introduction,2Guyatt GH Akl EA Crowther M Schünemann HJ Gutterman DD Lewis SZ Introduction to the ninth edition: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines.Chest. 2012; 141: 48S-52SAbstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar and Methodology3Guyatt GH Norris SL Schulman S et al.Methodology for the development of antithrombotic therapy and prevention of thrombosis guidelines: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines.Chest. 2012; 141: 53S-70SAbstract Full Text Full Text PDF PubMed Scopus (209) Google Scholar articles from the Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (AT9). These broad articles, as well as those that address specific content areas covered by the latest guidelines, can also be accessed at http://chestjournal.chestpubs.org. There have been several noteworthy advances in the methodology used to produce these guidelines since the last edition was published in 2008.4Hirsh J Guyatt G Albers GW Harrington R Schünemann HJ Antithrombotic and thrombolytic therapy: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition.Chest. 2008; 133: 110S-112SAbstract Full Text Full Text PDF PubMed Scopus (287) Google Scholar Additionally, AT9 marks the initial step of a transition in the American College of Chest Physicians (ACCP) process for guideline updating and publication. Although the importance of the topic and the nature of the evidence virtually guaranteed that these guidelines would be both comprehensive and hefty, readers will find new ideas woven into AT9. We salute the Executive Committee (EC) of AT9 for introducing innovative ways to deal with thorny issues. As expected, the EC recruited an outstanding group of international panelists who developed critical Patient, Intervention, Comparison, and Outcome (PICO) questions that served as the foundation of the literature review and formulation of final recommendations. In addition to methodologists and subject matter experts, readers will note important new additions to the panel. Health economists and experts on patient values and preferences were added to facilitate the consideration of issues related to resource allocation and variations in patient management related to individual and societal norms. The other new group of panelists consisted of "frontline" clinicians who treat patients on a daily basis. These physicians bore responsibility for keeping discussions relevant to the practicing physician and ensuring that the final recommendations could be implemented in the clinical arena. These innovations will help maintain the ACCP's position as a pioneer in guideline development methodology. The current environment mandates that guideline developers make every effort to avoid conflicts of interest that may influence recommendations. Ideally, all guideline panelists would be free of conflicts, but requiring this for AT9 would have eliminated individuals whose expertise was critical. Tackling this issue was a two-pronged effort between the Health and Science Policy Committee (HSP) of the ACCP and the AT9 EC. Before participating, all proposed panelists disclosed their extramural funding sources and financial relationships with industry for conflict of interest review by HSP's Policies and Procedures Subcommittee and subsequently the full HSP Committee. Furthermore, each panelist agreed to refrain from participating in relevant marketing activities, including commercially funded lectures, until 1 year following the guideline's publication. For AT9, 8% of nominees were disapproved because their conflicts were deemed unacceptable. In addition, the AT9 EC, for the first time in an ACCP guideline, formally considered the role of intellectual conflicts. Following a process described previously,5Guyatt G Akl EA Hirsh J et al.The vexing problem of guidelines and conflict of interest: a potential solution.Ann Intern Med. 2010; 152: 738-741Crossref PubMed Scopus (240) Google Scholar unconflicted methodologists played leading roles in the development and drafting of the final recommendations. Although panelists with intellectual conflicts participated in discussions on relevant recommendations, they were excluded from voting on the final recommendation. There has been increasing recognition by the ACCP HSP Committee that a new framework for developing, updating, and publishing guidelines is needed. Because the existing process has relied on updates of the entire guideline, revision has been a monumental effort that could only be undertaken every 3 to 4 years. In this era of increasingly rapid knowledge transfer, we faced the risk that our guidelines would become irrelevant. We also recognized the incredible power of the Internet to enhance the value of the guidelines. Furthermore, the increasing concern regarding pharmaceutical company funding of guideline development and dissemination, and the limited availability of other sources of funding, made it clear that the ACCP needed to decrease the cost of guideline production. The Living Guidelines Task Force was created to determine how best to respond to these concerns. After consultation with numerous experts and stakeholders, and in close collaboration with the CHEST editorial staff, the task force made several recommendations regarding guideline development and dissemination to the ACCP Board of Regents, who accepted these recommendations, summarized below. Instead of periodically convening a group of experts to redo a guideline in its entirety, for each guideline there will be a panel that will review new evidence on a yearly basis and determine which recommendations require updating. Information on those recommendations that are updated will be released on a periodic basis. This will allow much more timely updates and will reduce costs. The task force and the CHEST editorial staff also felt that moving away from print publication to electronic publication offered several advantages. Most important are the intrinsic advantages of electronic publication. Avoiding the time needed for printing and mailing the issue expedites the availability of the guidelines. Users have noted that the larger guidelines, with hundreds of pages, are difficult to navigate. Electronic versions will be more easily navigable and searchable. Electronic publication also allows the guidelines to be linked to additional relevant content such as underlying evidence, implementation tools, and patient education materials. Eventually, should evidence that could affect clinical practice become available after guideline publication, readers can be alerted to this even before the subsequent version of the guideline incorporates the evidence. Finally, a large component of the overall expense of the guidelines stems from the cost of paper publication and shipping (several hundred thousand dollars for AT8). The task force noted that electronic publication also provides the opportunity for the ACCP to become more environmentally friendly, saving >50 tons of paper with electronic publication of AT9 alone. AT9 represents the first step in the transition to the new publication process, with only the Introduction, Methodology, and Executive Summary of recommendations being printed on paper. In the future, print publication will be used when demanded by the needs or scale of the content, perhaps, for example, for the first edition of a new guideline. All institutions, including the ACCP, must adapt to societal and technologic changes to maintain relevance. The HSP committee believes that the modifications to the Guideline development and dissemination process described above will drive further improvements in Guideline quality and impact. We will closely monitor the effect of these changes on satisfaction with the Guidelines among both our members and external users. ACCP members, other end users, and our patients deserve no less. Other contributions: The authors acknowledge Sandy Zelman Lewis, PhD, for her support of the ACCP HSP, her zealous pursuit of excellence in the ACCP Guideline process, and her critique of this manuscript. /cms/asset/16a6540b-7537-4fed-a2d9-86f13cb70d79/mmc1.mp3Loading ... Download .mp3 (22.43 MB) Help with .mp3 files Supplement AudioPart 1: Advancing Evidence-Based Medicine: ACCP MethodologyDuration: 48:58 minModerator: D. Kyle Hogarth, MD, FCCP, Podcast Editor, CHESTParticipants: Gordon H. Guyatt, MD, FCCP; Ian T. Nathanson, MD, FCCP /cms/asset/1befe20c-8b9c-4b7b-89e4-e9fe8ac3533b/mmc2.mp3Loading ... Download .mp3 (43.97 MB) Help with .mp3 files Supplement AudioPart 2: New Drugs, New Recommendations: What Clinicians Must KnowModerator: D. Kyle Hogarth, MD, FCCP, Podcast Editor, CHESTParticipants: Mark A. Crowther, MD; David A. Garcia, MD