Trustworthiness and public investment in clinical practice guidelines

Although clinical practice guidelines should be based on high quality research and practice experience, they vary in their relevance to practice, use of evidence, and other factors. Researchers have now developed the Guideline Trustworthiness, Relevance, and Utility Scoring Tool (G-TRUST), a tool for clinicians to identify useful practice guidelines.

Twenty-two experts in evidence-based medicine, 17 developers of high-quality guidelines, and one consumer representative participated in a modified Delphi process to obtain consensus on a checklist of items and their relative impact on guideline quality. More than 75 percent of experts found three of the eight checklist items to be major indicators of guideline usefulness and, in comparison to a reference standard (the AGREE tool), a scoring system was developed identifying guidelines as "useful," "may not be useful," and "not useful."

The eight-item checklist identified 92 percent of low-quality guidelines and disqualified many high quality guidelines because of a stricter definition of trustworthiness, including more stringent conflict of interest requirements. With the proliferation of practice guidelines, numbering in the thousands, the authors call for research to determine the reliability of G-TRUST and to examine how the tool might interact with technology, such as smart phone applications.

In a related editorial, Michael LeFevre MD, MSPH, former Chair of the US Preventive Services Task Force, considers the past, present, and future of clinical practice guidelines. Although G-TRUST simplifies the evaluation of guidelines, their development remains a costly, rigorous, and labor-intensive process. Furthermore, although they are intended to help bring scientific evidence to clinical care, the growing number of guidelines developed by consensus panels, and an increasing reliance upon them, signals a return to authority-based medicine.

To produce guidelines that will be most useful to clinicians and patients, he contends, guidelines must be a public funding priority. A competitive process through the Agency for Healthcare Research and Quality, such as that for funding research grants, would help ensure that physicians and patients have access to usable, trustworthy guidelines. "Public investment," LeFevre states, "is essential."