Review
Clinical Practice Guidelines: A Primer on Development and Dissemination

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Abstract

Trustworthy clinical practice guidelines should be based on a systematic review of the literature, provide ratings of the quality of evidence and the strength of recommendations, consider patient values, and be developed by a multidisciplinary panel of experts. The quality of evidence reflects our certainty that the evidence warrants a particular action. Transforming evidence into a decision requires consideration of the quality of evidence, balance of benefits and harms, patients' values, available resources, feasibility of the intervention, acceptability by stakeholders, and effect on health equity. Empirical evidence shows that adherence to guidelines improves patient outcomes; however, adherence to guidelines is variable. Therefore, guidelines require active dissemination and innovative implementation strategies.

Section snippets

Historical Perspective

Until the 1970s, medical actions were indirectly regulated through the training and credentials granted by medical schools or state authorities; however, such credentialing proved to be an insufficient guarantee of quality.5 Further standardization and organization of the medical profession necessitated the development of guidelines. Guidelines in their current form started in the 1970s and were primarily based on the consensus of expert panels (eg, the National Institutes of Health Consensus

Evaluating the Quality of Evidence

A systematic review is a mechanism to reduce the risk of biased selection of evidence and should be conducted once the scope and preliminary questions of the guideline are determined. Meta-analysis may or may not be appropriate, but a systematic review is always needed. In the context of a guideline, the quality of evidence (also called certainty in the evidence, strength of the evidence, and confidence in the effect estimates) reflects the extent of our confidence that the estimates of an

From Evidence to Recommendation

The beginnings of evidence-based medicine have demonstrated a great desire to base decision making on evidence (as opposed to the previous approach of depending on expert opinion). However; evidence-based practitioners realized very quickly that evidence alone is insufficient for decision making. Hence, the second principle of evidence-based medicine acknowledged that decisions should also consider several nonevidence factors.30 For example, chemotherapy can extend survival in lymphoma but

Determining the Strength of a Recommendation

The National Academy of Medicine and other authorities18, 19, 20, 21 have indicated that a key criterion of a trustworthy guideline is that a recommendation given to a patient or a population should have a strength attached to it. For example, in GRADE, recommendations are labeled as strong or weak (also called conditional or discretionary). This strength reflects the extent to which we can be confident that the desirable effects of an intervention outweigh the undesirable effects.36 An example

Where to Find Guidelines?

The National Guideline Clearinghouse is a public resource that is supported by the Agency for Healthcare Research and Quality. Guidelines indexed in this register have to meet certain criteria, particularly, being based on a systematic review of the evidence and documenting an assessment of the benefits and harms of the recommended care and alternative care options.4 Another way to find guidelines is to search websites of professional societies relevant to a particular topic. Guidelines can

How to Judge the Quality of a Guideline?

There are more than 20 tools available to appraise a guideline.39 Some tools focus on implementation.40 The AGREE (Appraisal of Guidelines, Research, and Evaluation) Collaboration developed the AGREE II, which is the most validated and extensively used tool. The AGREE II is a generic instrument that aims to assess the process of guideline development and reporting and has 23 items grouped into 6 domains (scope and purpose, stakeholder involvement, rigor of development, clarity of presentation,

Implementation From the Perspective of a Clinician-Patient Dyad

The key information needed to implement a recommendation includes a clear description of the population to whom a recommendation is appropriate, the baseline risk of this population, the quality of evidence, and the strength of the recommendation. An example of a recommendation that contains these 4 pieces of information is presented in Table 5.

When the recommendation is strong, clinicians should offer the intervention to almost all their eligible patients and convey high confidence that the

Limitations and Future Needs

A large proportion of published guidelines were reported to have limited rigor and did not meet all the criteria for a trustworthy guideline.59, 60, 61 Patients or methodologists were not included in the guideline development process in most guidelines (71% and 86%, respectively).62 Guidelines also tend to address the common or average patient. For example, 1 study demonstrated the absence of incorporating the impact of multiple chronic conditions, sociopersonal context, and patient preferences

Conflicts of Interest

It is well-known that conflicts of interest affect the opinions and recommendations of experts and can compromise guideline validity.78 Intellectual conflicts are common but remain implicit and are rarely addressed (compared with financial ones). Forming guideline panels without conflicted experts (who are more likely to have the most expertise and knowledge in a particular field) may lead to guidelines devoid of expertise and may impair guideline credibility and uptake. Therefore, if excluding

Conclusion

Trustworthy clinical practice guidelines require a systematic review to select the best available evidence and should rigorously evaluate the quality of evidence and incorporate nonevidence factors to transform evidence into a decision. Empirical evidence shows that guidelines improve patient outcomes; however, adherence to guidelines is variable. Therefore, guidelines require active dissemination and innovative implementation strategies.

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