In an age when evidence-based care is increasingly important, how trustworthy are current clinical practice guidelines?
Researchers at the University of Michigan Comprehensive Cancer Center looked at 169 cancer clinical practice guidelines for lung, breast, prostate and colorectal cancers and found that none of the guidelines fully met standards set in 2011 by the Institute of Medicine. Of eight criteria, the guidelines on average met fewer than three.
"None of the current guidelines we looked at meet all of the standards, but some of these are really good guidelines. It begs the question: How pragmatic are the Institute of Medicine standards? In some ways, are these standards too strict?" says lead study author Sandra Wong, M.D., M.S., associate professor of surgery at the University of Michigan Medical School.
The IOM standards for clinical practice guidelines were developed to ensure that guidelines truly reflect the best quality of care. The standards cover eight criteria, including disclosing conflicts of interest, using systematic reviews of the literature, seeking external review and updating recommendations regularly.
In this new study, published in the Journal of Clinical Oncology, researchers reviewed clinical practice guidelines for the four leading causes of cancer deaths – lung, colorectal, breast and prostate cancer. Guidelines covered recommendations for screening, diagnosis, treatment or follow-up care.
On average, guidelines met 2.75 of 8 major criteria and 8.24 of 20 sub-criteria. The most common gaps were in managing conflict of interest and including patients or other lay people in the process.
"The IOM was trying to define what you need to have trustworthy guidelines. But if a group does not include a forum for public comment on the guidelines, does that make the guideline less trustworthy? Is that as important as whether they incorporate a systematic review of the literature? One consideration is that perhaps all standards should not be weighted the same across the board," Wong says.
She also suggests creating a balance between ideal standards and what is practical to ensure guidelines can be put in place in a timely manner. Some guidelines already take more than a year to create.
"Everybody is much more worried about quality standards and evidence based care. Clinicians are inundated with a lot of information and must be able to rely on guidelines produced by major professional organizations. At the same time, standards must ensure a practical and pragmatic approach to creating guidelines," Wong says.
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Journal of Clinical Oncology, DOI: 10.1200/JCO.2012.46.8371