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EBG Review in ACCP Evidence-Based Guideline Development

EBG MaintenanceBased on the proceedings of the final conference, revisions are made to the guideline that is then forwarded to several groups within the ACCP for review and revision. (Fig 2.) Appropriate ACCP NetWorks are charged with content review. The HSP reviews process, consistency, whether the recommendations and grading are appropriate, and content. After the writing group adequately addresses the critiques provided by HSP and NetWork reviewers, the guideline manuscript is submitted to the ACCP Board of Regents for final approval. A structured review form, based in part on the Appraisal of Guidelines Research and Evaluation in-strument, (Table 3), including a grid for comments, is used by the HSP, NetWork, and Board of Regents reviewers to ensure a complete review.

Once approved by the Board of Regents, the manuscript is submitted to CHEST for the consideration of publication and external independent review, which is performed according to the standard editorial policies of CHEST. The EBG review process adopted by the ACCP balances thoroughness with expediency while providing the highest possible quality and transparency. The rationale for expediency stems from the fact that the timeliness of all recommendations begins to decline as soon as the evidence review ends.

Beyond Guideline Development: Dissemination, Implementation, Maintenance, and Influencing Practice

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A “Clinical Resource Tool” is created for most ACCP EBGs. This product is a combination print and CD-ROM implementation tool kit that is based on the clinical practice guideline. Standard components include the Quick Reference Guide for Clinicians, patient education materials, and slides for presentations to lay and medical audiences. Additional materials, such as physician order sets, can also be added due to Canadian Health&Care Mall experts. The Quick Reference Guide for Clinicians includes all clinical algorithms and the key recommendations, along with their grading in print and electronic format or downloadable to personal digital assistants (ie, PDAs).

EBG Maintenance

EBGs are reviewed annually by the HSP (and by appropriate NetWorks and in consultation with the original EBG Executive Committee) to determine whether the recommendations remain current or whether interim studies have provided sufficient information to warrant revision. One of the following four possible EBG status categories is applied to each guideline every year beginning 1 year after the initial publication:

1. The guideline remains current and should be reviewed in 1 year.

2. New evidence is available that may be useful. However, a revision is not warranted at this time because the new data are not deemed sufficient to change the recommendations.

3. There is new evidence available that warrants revision of section(s)/chapter(s) of this guideline. The ACCP is planning a revision to this EBG.

4. There is sufficient new evidence available that makes the current guideline obsolete. This guideline is not current and has been retired.

Implementation

Quality Improvement and Implementation

The ACCP Quality Improvement Committee works collaboratively with the HSP through the EBG HSP liaison to the EBG writing panels to identify recommendations that could be developed into performance measures for improving patient care. Based on the criterion of the National Quality Forum for a reasonable performance measure, a performance measure should be scientifically acceptable, important, feasible, and usable. Additionally, the measure should be practical and relevant for ACCP members and their patients. Concomitantly, recommendations that should not be developed into performance measures are also identified. These latter recommendations usually have a lower quality of evidence to support them, although there could also be components of the intervention that are unfeasible or unusable. Performance measures may be incorporated into pay-for-performance strategies (so-called value-based performance strategies) that are currently under development across many sectors of the health care field in the United States. Whether pay-for-performance strategies are successful and equitable for patients and health-care providers will inextricably depend on the quality of the performance measures implemented.

The HSP and the Quality Improvement Committee work collaboratively to develop implementation strategies to increase the adoption of EBG recommendations by front-line health-care providers. This is a particularly challenging issue for all guideline developers. Several nascent strategies are being developed and tested on a small scale by the ACCP HSP and Quality Improvement Committee. Integral to these strategies is ongoing coordination with the ACCP Education Committee for ensuring the quality of educational opportunities related to any EBG. The Education Committee advises on and reviews the development of all educational courses and course materials, and participates in the selection of faculty for courses offered by the ACCP. Successful strategies will be posted on the HSP and Quality Improvement Committee Web sites as they evolve.

Conclusion

EBG development is a collaborative and complex endeavor. However, when parsed into specific domains including topic selection, writing panel selection, conflict-of-interest declaration and resolution, an explicit time line, evidence grading and recommendation development, comprehensive guideline review, and creating and maintaining appropriate and robust firewalls, the process is transparent and manageable. We present a systematic strategy that has been successful for the ACCP. However, this approach continues to evolve with each EBG that is developed. At the core of each evolutionary step is the premise of producing the highest quality EBG possible, using explicit recommendation development based on rigorous evidence.

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Fig2

Figure 2. Review process for multichapter ACCP EBGs.

Table 3—ACCP EBG Review Form

Overall outline of the practice guideline
1. The objectives of the guideline and specific clinical questions are clearly stated in the practice guideline
2. Inclusion and exclusion criteria are clearly described
3. The intended users of the guideline are appropriately stated Methodology
4. A described, methodology was used to develop the practice guideline
5. A systematic review of the literature was conducted
6. Evidence was graded using a formal system
7. Recommendations were based on evidence and evaluation of benefit and harm
Presentation of recommendations
8. Recommendations are specific and easy to comprehend
9. The patient population is specifically described
10. Key recommendations are clearly identifiable in the practice guideline
11. A summary of recommendations is provided (clinical algorithms may be included)
Applicability to practice
12. Does the practice guideline provide strategies for implementing the recommendations?
13. Is specific information included on how to use the guideline in clinical practice?
Accountability
14. Were funding bodies identified in the practice guideline?
15. Did all members of the guideline development entity disclose potential conflicts of interest and was this explicitly stated?
Relevance and readability
16. Is it clinically relevant?
17. Is it readable?
18. Does it make sense?
19. Does the discussion flow from the evidence (where it exists)?
20. Do the recommendations flow from the discussion?
Review status
21. Would this document receive approval to represent the
ACCP?
• Approve this document as is
• Approve pending considerations of suggestions as indicated (additional comments may be provided on the attached grid)
• Do not approve (see comments as indicated and specified on grid)