Chapter 7: Evidence-Based Clinical Practice Guidelines

Learning Objectives

After completing this chapter, the reader will be able to

• Define clinical practice guidelines.

• Define evidence-based medicine.

• Discuss the role of the pharmacist in development and use of these evidence-based clinical practice guidelines.

• Explain the methodology for development of evidence-based clinical practice guidelines.

• Describe the GRADE system for grading the quality of evidence and strength of recommendations.

• Describe the AGREE II instrument for evaluating clinical practice guidelines.

• Identify the key issues involved in the implementation of clinical practice guidelines.

• Identify sources of published clinical practice guidelines.

Key Concepts

1. Clinical practice guidelines are recommendations for optimizing patient care that are developed by systematically reviewing the evidence and assessing the benefits and harms of health care interventions.

2. Evidence-based medicine (EBM) is a philosophy of practice and an approach to decision making in the clinical care of patients that involves making individual patient care decisions based on the best currently available evidence.

3. Evaluation of the quality of a guideline and the appropriateness of its use in a given setting depends primarily on an ability to distinguish methods that minimize potential biases in development.

4. The definition of the clinical questions to be addressed by a guideline is a key step that provides direction for the activities to follow.

5. The quality of the evidence that forms the basis for recommendations is a key aspect for interpretation and use of a practice guideline.

6. The advantage of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system is that all of the evidence that is most important for making the decision has been judged with explicit criteria, the judgments are made transparent, evidence profiles and summary of findings tables have been created, consequently facilitating the use of best evidence.

7. Prior to selecting a clinical practice guideline for implementation in a health care system or for personal use by a health care professional, it is important that the quality of published guidelines be evaluated. Perhaps the most useful tool available for evaluating clinical practice guidelines is the one created by the Appraisal of Guidelines for Research and Evaluation (AGREE) collaboration.

8. The most effective methods for implementing guidelines to achieve the desired effects of improved quality of care have not been determined.

9. Complete clinical practice guidelines can be found on Web sites such as the National Guideline Clearinghouse and in the peer-reviewed medical literature located by use of secondary databases.

Introduction

❶ Clinical practice guidelines are recommendations for optimizing patient care that are developed by systematically reviewing the evidence and assessing the benefits and harms of health care interventions.¹ These interventions may include not only medications but other types of therapy, such as radiation, surgery, and physical therapy. Clinical practice guidelines are developed by a variety of groups and organizations including federal and state government, professional associations, managed care organizations, third-party payers, quality assurance organizations, and utilization review ...