Guidelines

Question 1

A clinical practice guideline is a statement that includes recommendations intended to __ patient care, and are based on __ __ of __ and an assessment of __ and __ of ___ care approaches.

Answer 1

A clinical practice quideline is a statement that includes recommendations intended to optimize patient care, and are based on systematic review of evidence and an assessment of benefits and harms of alternate care approaches.

Question 2

guidelines in clinical practice provide an ___ __ ___ for clinical practice. It facilitates the translation of __ __ into clinical practice.

Answer 2

They provide an evidence-based framework
for clinical practice. It facilitates the translation of new evidence into clinical practice.

Question 4

guidelines as a basis for healthy policy:

• drugs and technologies recommended by guidelines will often then undergo __ __ ___ assessment and consideration for public funding.

Answer 4

drugs and technologies recommended by guidelines will often then undergo provincial health technology assessment and consideration for public funding.

recommendations by leaders in the field can catalyze public health policy so that specific drugs can be made available to the public in a cheap manner or during an emergency situation.

Question 5

guidelines as a quality framework:

• guidelines often inform __ __ (ie measures that indicate that good “care” is being provided). this forms the basis for a health system evaluation and __ __.

Answer 5

• guidelines often inform quality indicators (ie measures that indicate that good “care” is being provided). this forms the basis for a health system evaluation and quality improvement– like audit and feedback, benchmarking.

Question 6

outline how guidelines are just one step in a larger process of care quality improvement

Answer 6

Question 7

describe the difference between clinical evidence and experience

Answer 7

clinical experience includes understnading the lived experience, the clinical complexity, the social situation, and economic and practical considerations. clinical evidence is evidence seen in perfect hospital conditions (ex no no-shows, no other health issues going on)

Question 8

Evidence-based medicine is not “cookbook medicine”. It requires a ___-___ approach that integrates best ___ evidence with individual clinical ____ and patient choice.

Answer 8

Evidence-based medicine is not “cookbook medicine”. It requires a bottom-up approach that integrates best external evidence with individual clinical experience and patient choice.

Question 9

outline the process of shared decision making

Answer 9

both the physician and patient bring valuable information to the table. both parties should be considered when making guidelines and treating cases.

Question 10

T/F we have guidelines about how to make new guideliens

Answer 10

true. in the annals of internal medicine, the guidelines international network set international standards for clinical practice guidelines.

Question 11

Outline the 10 commandments of guidelines

RMConS ECARP EUSF

Answer 11

1. representative guideline panel: are all people who might be affected by this guideline erpresented in the panel?
2. set out methods for evidence evaluation and consensus aprior: are all methods clear and transparent?
3. Disclose all conflicts
4. scope of guidelines should be clearly stated: what are the objectives of the guidelines, what kind of guidance is being provided?
5. rigorous evidence review methods
6. guidelines should be clear and actionable: clear language, clear statement or expected beneftis vs harms relative to alternatives.
7. rating of evidence for recommendations: did the pancel use a systematic process to evaluate the underpinning evidence? is the strength of evidence clearly stated?
8. Peer review and stakeholder engagement: have the guidelines being externally reviewed and vetted by a knowledgeable third party?
9. Guideline expieration and updating: is there a claer statement when the guidelines will be re-examined, updated or decomissioned?
10. role of sponsoring organization/financial support disclosed.

Question 12

Outline the GRADE (grading of recommendations, assessment and evaluation (GRADE) Framework.

Answer 12

it’s used to handle 7th commandment of guidelines: rating of evidence for recommendations ((Did the panel use a systematic process to evaluate the underpinning evidence? Is the strength of evidence clearly stated?)

the GRADe framework was created by guyatt in an attempt to harmonize granding processes and create a common more comprehensive approach to evidence review. it considers not only the evidence but tries to capture the perspective of the agent (provider), object (patient) and context (system) of the recommendations.

Question 13

GRADE step 1 and it’s considerations

Answer 13

grade step 1: establishing quality of evidence.

3 considerations:

1. study design
   a. randomized trials are higher confidence
   b. observational studies: lower confidence.
2. consider lowering or rasiing level of confidence
3. final level of confidence rating.

Question 14

Grade step 2 and its considerations

Answer 14

grade step 2: consider lowering or raising level of confidence of the evidence.

there are four considerations

1. quality of evidence

2. balance between benefits/harms

3. patient preferences and values

4. cost and resource use.

in the end the strength of recommendation is based on the balance of advantages and disadvantages of a given intervention.

Question 15

Strong vs Weak GRADE recommendations

Answer 15

Question 16

PROS of the CPG (Clinical practice guidelines)

Answer 16

1. provides a convenient resource to busy clinicans on best practice
2. they can be a powerful tool in promoting healthy/helpful policy
3. they define quality and cna inform a safer more effective health care system

Question 17

CONS of CPG

Answer 17

1. in the absence of any central coordination, we get too many guidelines that say different things.

Only 32% of guidelines on hypertension were consistent in direction and strength 27% consistent in direction, inconsistent in strength 42% inconsistent in direction
2. Evidence burdened vs. Evidence-based,
reactive vs. reflective

3. Divergence in recommendations across
guideline bodies suggests that fundamental
problems with development process (lack of
standardization, bias mitigation, conflicts)

-A review of 421 clinical practice guidelines, evaluated for quality based on the Agree II instrument Only 23.5% of CPGs were found to be of high quality

4. too many experts, not enough primary care or patient involvement.

Question 18

CPG must have a quadruple aim. Explain

Answer 18

must take into consideration:

• clinical outcomes
• cost efficiency
• patient experience
• clinician experience.

Question 19

Guidelines can be:

1) Basis for health ____

• a. Drugs and technologies recommended by guidelines will often then undergo provincial __ ___ ___ and consideration for public funding
• b. Recommendations by leaders in the field can catalyze public health policy

2) ___ framework

• a. Guidelines often inform quality indicators (i.e measures that indicate that good “care” is being provided)
• b. Forms the basis for health system evaluation and quality improvement

Answer 19

Guidelines can be:

1) Basis for health POLICY

• a. Drugs and technologies recommended by guidelines will often then undergo provincial HEALTH TECHNOLOGY ASSESSMENT and consideration for public funding
• b. Recommendations by leaders in the field can catalyze public health policy

2) QUALITY framework

• a. Guidelines often inform quality indicators (i.e measures that indicate that good “care” is being provided)
• b. Forms the basis for health system evaluation and quality improvement

Question 20

In their most fundamental form CPGs consist of two components:

Answer 20

1) The first involves a comprehensive and unbiased, i.e., systematic, review of the evidence that informs the questions that the guideline seeks to tackle.

2) The second involves moving from a thorough understanding of the state of research evidence to the creation of recommendations.
• However, not all recommendations carry the same degree of importance and distinguishing between stronger and weaker statements linked to a level of quality and certainty in the evidence base is something that guideline panels struggle with.

Question 21

Q1. Which of the following factors do NOT need to be considered by guideline panels as they develop recommendations from a body of evidence?

a. The certainty in the evidence base in terms of confidence in estimates of effects
b. The resource considerations related to the recommendation
c. The feasibility of measuring whether recommendations are followed by clinicians
d. The forcefulness of the recommendation i.e., strong, or weak

Answer 21

C- think GRADE criteria. D is mandatory for sure.

Question 22

Q2. The GRADE methodology informs guideline development in which of the following domains?

a. Provides the methodology to conduct systematic reviews of the literature
b. Establishes the relative importance of the various outcomes relevant to the PICO questions being considered
c. Informs the make-up of a guideline panel to optimize stakeholder representation
d. None of the above

Answer 22

b

Question 23

Q3. In the CTS clinical practice guideline (update 2019) on the use of dual therapy (inhaled LAMA/LABA) for patients who experience symptoms, the recommendations are changed (from suggestion to recommendation). The best explanation for this is:

a. The addition of patient panelists
b. Limited consideration of conflict-of-interest considerations for panelists with ties to companies that make the combo drugs
c. Recent RCT evidence on use of dual therapy (LAMA/LABA) for patients with COPD
d. Specific consideration of shared decision-making by incorporating values and preferences

Answer 23

C

Question 24

Q4. In the COPD clinical practice guideline, the use of ICS (inhaled corticosteroids) is not recommended as monotherapy for patients with COPD, based on consensus. What do we mean by “consensus”?

a. Consistent evidence from randomized controlled trials without important limitations, or exceptionally strong evidence from observational studies. (1A)
b. Evidence for at least one critical outcome from observational studies, case series or randomized controlled trials, with serious flaws or indirect evidence. (1C)
c. In instances where there was insufficient evidence, but a recommendation was still warranted, a suggestion was developed. (consensus-based)
d. None of the above

Answer 24

C

Question 25

what is a consensus based recommentation

Answer 25

In instances where there was insufficient evidence, but a recommendation was still warranted, a suggestion was developed.

Question 26

What is the impact of uncertainty associated with the evidence and values used in the guidelines?

Answer 26

Uncertainty is captured in the strength of the recommendations and is based on the underlying quality of evidence and the relative importance of the outcomes assessed.

Uncertainty around the evidence for a particular outcome arises from the risk of bias, imprecision, indirectness, inconsistency, and potential for publication bias, that is present in the underlying evidence. Uncertainty also arises when one strategy is more favourable for a given outcome while the other is more favourable for a different outcome (e.g., treatment failure vs. side effects). In going from evidence to recommendations the panels considered variability around values and preference in formulating recommendations.

Question 27

Note from small group:

In their most fundamental form CPGs consist of two components. The first involves a comprehensive and unbiased, i.e., systematic, review of the evidence that informs the questions that the guideline seeks to tackle. The second involves moving from a thorough understanding of the state of research evidence to the creation of recommendations. However, not all recommendations carry the same degree of importance and distinguishing between stronger and weaker statements linked to a level of quality and certainty in the evidence base is something that guideline panels struggle with.

. The problems associated with CPG development and implementation are myriad and include issues related to conflicts of interest, stakeholder representation, wishy-washy recommendations that represent compromise among expert panelists and possible misinterpretation of the evidence base to name a few.

One of the greatest challenges facing the usefulness of CPGs is the variation in methods and classification schemes that organizations use to develop guidance for clinicians. The GRADE methodology is emerging as the international standard for CPG development.