Users’ guide to the surgical literature: how to evaluate clinical practice guidelines

Clinical practice guidelines (CPGs) are defined in the literature as “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.”12–15 They distill a large body of literature on a topic into a format that is high-yield and easy for physicians to use. Worldwide, surgeons perform 200 million procedures annually.16 There is constant effort to optimize this complex and expensive health care facet.16 Surgeons are faced with difficult management decisions while balancing evidence-based recommendations.17 When trial evidence exists, it often cannot be perfectly applied to specific patient presentations. It is difficult to independently condense primary research for each patient. Moreover, health care providers and insurers are increasingly concerned with quality improvement and cost effectiveness. Guidelines aim to balance these factors,12,15 and direct consistent and reliable care.17 The number of surgical guidelines available in the literature is increasing. However, CPGs vary in their quality and sometimes deviate from high methodological rigor.16 It is necessary for surgeons to be able to appraise CPGs before deciding to adopt their recommendations. Since 1990, CPGs have been an increasingly popular tool influencing physician practice.18,19 More than 20 tools to interpret and appraise CPGs have been published;14 the latest is the AGREE-II instrument (appraisal of guidelines for research and evaluation).13 It was originally released in 2003 to address guideline development, reporting and evaluation. Two further studies,20,21 have refined the instrument, now recognized as the methodological standard in guideline evaluation.14 In this article, we discuss a practical approach to the appraisal of a CPG; Box 1 contains the key items readers should consider when using a CPG in surgery. As in previous users’ guide to the surgical literature articles,22 we use a condensed framework to approach a guideline from a surgical perspective. This will provide surgeons with a practical approach to interpreting and applying recommendations in a CPG, using the guideline by Robson and colleagues11 as an example. Box 1. Users’ guides for an article on clinical practice guidelines Are the recommendations valid? 1. Is there a clear statement of a clinical problem? 2. Who was involved in guideline development (i.e., authors, reviewers, patients, readers)? 3. How is the guideline reviewed? 4. What literature are recommendations based on? What recommendations are made? 5. Are useful recommendations presented? 6. How do authors move from evidence to recommendations? Will the results help me in caring for my patients? 7. Were all outcomes considered (surgical outcomes versus natural course of disease)? 8. Will I be able to implement these recommendations? Are the recommendations valid? Is there a clear statement of a clinical problem? Like other publications, CPGs address a defined problem in a specific group of patients. Surgeons must always consider whether the CPG recommendations can be applied to their own patients.15,23 The PIPOH items (patient population, intevention(s), professionals/patients, outcomes to be considered, health care setting) are suggested in the ADAPTE process (www.adapte.org) to frame the content and clinical question in a guideline.24 Readers should use these categories to decide if the recommendations presented are representative of their patient and treatment goals. Surgeons are cautioned in applying CPGs not designed for their patient populations.25 Subtle differences in any category can alter the CPG’s applicability. Robson and colleagues11 summarize the management of venous ulcers in 8 categories: diagnosis, compression, infection control, wound bed preparation, dressings, surgery, adjuvant agents and long-term maintenance. However, the guideline does not include specific PIPOH criteria. For example, the authors need to be more specific in Recommendation #6.3: “Less extensive surgery on the venous system, such as superficial venous ablation, endovenous laser ablation, or valvuloplasty, especially when combined with compression therapy, can be useful in decreasing the recurrence of venous ulcers (Level I).” The reader must carefully consider patient population and health care setting in this recommendation. Venous ulcers are associated with comorbidity. If our hypothetical patient had diabetes or an inflammatory disorder, interventions would differ. Further, procedures such as endovenous laser ablation may not be available in every health care setting.