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The systematic guideline review : method, rationale, and test on chronic heart failure

By Christiane Muth, Jochen Gensichen, Martin Beyer, Allen Hutchinson and Ferdinand M. Gerlach


Background Evidence-based guidelines potentially improve healthcare. However, their de-novo-development requires substantial resources - especially for complex conditions, and adaptation may be biased by contextually influenced recommendations in source guidelines. In this paper we describe a new approach to guideline development - the systematic guideline review method (SGR), and its application in the development of an evidence-based guideline for family physicians on chronic heart failure (CHF). Methods A systematic search for guidelines was carried out. Evidence-based guidelines on CHF management in adults in ambulatory care published in English or German between the years 2000 and 2004 were included. Guidelines on acute or right heart failure were excluded. Eligibility was assessed by two reviewers, methodological quality of selected guidelines was appraised using the AGREE-instrument, and a framework of relevant clinical questions for diagnostics and treatment was derived. Data were extracted into evidence tables, systematically compared by means of a consistency analysis and synthesized in a preliminary draft. Most relevant primary sources were re-assessed to verify the cited evidence. Evidence and recommendations were summarized in a draft guideline. Results Of 16 included guidelines five were of good quality. A total of 35 recommendations were systematically compared: 25/35 were consistent, 9/35 inconsistent, and 1/35 unratable (derived from a single guideline). Of the 25 consistencies, 14 based on consensus, seven on evidence and four differed in grading. Major inconsistencies were found in 3/9 of the inconsistent recommendations. We re-evaluated the evidence for 17 recommendations (evidence-based, differing evidence levels and minor inconsistencies) the majority was congruent. Incongruencies were found, where the stated evidence could not be verified in the cited primary sources, or where the evaluation in the source guidelines focused on treatment benefits and underestimated the risks. The draft guideline was completed in 8.5 man-months. The main limitation to this study was the lack of a second reviewer. Conclusions The systematic guideline review including framework development, consistency analysis and validation is an effective, valid, and resource saving-approach to the development of evidence-based guidelines

Topics: ddc:610
Year: 2009
OAI identifier: oai:publikationen.ub.uni-frankfurt.de:6621

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  1. (1960). A coefficient of agreement for nominal scales. Educ Psychol Meas
  2. (2002). A: Current evidence supporting the role of diuretics in heart failure: a meta-analysis of randomized controlled trials.
  3. (1995). A: Evidence based medicine: an approach to clinical problem-solving. BMJ
  4. (2005). A: The use of B-type natriuretic peptides (BNP and NT-proBNP) in the investigation of patients with suspected heart failure.
  5. (1995). ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force
  6. (2005). Adapting national and international leg ulcer practice guidelines for local use: the Ontario Leg Ulcer Community Care Protocol. Adv Skin Wound Care
  7. (2005). Adherence to guidelines is a predictor of outcome in chronic heart failure: the MAHLER survey. Eur Heart J
  8. (2001). Affairs & Veterans Health Administration: Pharmacy Benefits Management Strategic Healthcare Group and the Medical Advisory Panel. The pharmacologic management of chronic heart failure.
  9. (2002). AGREE Collaboration: Inside guidelines: comparative analysis of recommendations and evidence in diabetes guidelines from 13 countries. Diabetes Care
  10. (2004). AJ: A systematic review of the diagnostic accuracy of natriuretic peptides for heart failure. Arch Int Med
  11. (2000). Alem F: Evaluation of community acquired pneumonia guidelines.
  12. (2007). AM: Essential elements of a technology and outcomes assessment initiative. JAMA
  13. American College of Cardiology's Foundation: [http://www.acc.org/ clinical/bethesda/beth28/9991/convrted/]. accessed
  14. (2001). American Heart Association: Guideline for the management of heart failure caused by systolic dysfunction: Part I. Guideline development, etiology and diagnosis. Am Fam Physician
  15. (2001). American Heart Association: Guideline for the management of heart failure caused by systolic dysfunction: Part II. Treatment. Am Fam Physician
  16. (2009). Anglo-German Foundation for the
  17. (2004). AR: Evidence-based guidelines in laboratory medicine: Principles and methods. Clin Chem
  18. (1999). Are guidelines following guidelines? The methodological quality of clinical practice guidelines in the peer-reviewed medical literature. JAMA
  19. (2006). Assessing the diagnostic test accuracy of natriuretic peptides and ECG in the diagnosis of left ventricular systolic dysfunction: a systematic review and meta-analysis.
  20. (2004). Baerheim A: Guidelines, evidence, and cultural factors. Comparison of four European guidelines on uncomplicated cystitis. Scand J Prim Health Care
  21. (2008). Bunting PS: Mass colorectal cancer screening: Methodological quality of practice guidelines is not related to their content validity. Clin Biochem
  22. (2001). Canadian Cardiovascular Society: The
  23. (2004). Canadian Cardiovascular Society: The 2002/3 Canadian Cardiovascular Society consensus Guideline. Update for the diagnosis and management of heart failure. [http://www.ccs.ca/ download/CCSHFConsUpdateDraft0103EMail.pdf]. Accessed
  24. (2005). Cash interests taint drug advise. Nature
  25. (2007). Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Glycemic control and type 2 diabetes mellitus: the optimal hemoglobin A1c targets. A guidance statement from the American College of Physicians. Ann Intern Med
  26. (1999). Clinical guidelines. Potential benefits, limitations, and harms of clinical guidelines. BMJ
  27. (2003). Clinical System Improvement: Health care guideline. Congestive heart failure in Adults.
  28. (2007). Competition on outcomes and physician leadership are not enough to reform health care. JAMA
  29. (2006). Conflict between guideline methodologic quality and recommendation validity: a potential problem for practitioners. Clin Chem
  30. (2002). Council of Europe: Developing a methodology for drawing up guidelines on best medical practices. (Recommendation (2001)13 and explanatory memorandum
  31. (1999). Cultural basis for differences between US and French clinical recommendations for women at increased risk of breast and ovarian cancer. Lancet
  32. (2004). Current epistemological problems in evidence based medicine.
  33. (2001). Den: Guidelines for appropriate care: the importance of empirical normative analysis. Health Care Anal
  34. (1999). Derese A: European general practice guidelines: a step too far?
  35. (2002). Detsky AS: Relationships between authors of clinical practice guidelines and the pharmaceutical industry. JAMA
  36. (2007). Detsky AS: What is the different about the market for health care? JAMA
  37. (1994). Development of the AHCPR-sponsored heart failure guideline: methodological and procedural issues.
  38. (2006). eds.: Health policy developments. Issue 4: Focus on access, primary care, health care organization.
  39. (1999). Empirical evidence of design-related bias in studies of diagnostic tests.
  40. (2006). et al.: Adaptation of clinical guidelines: literature review and proposition for a framework and procedure.
  41. (2004). et al.: Rates of hyperkalemia after publication of the randomized aldactone evaluation study.
  42. (1998). Evaluating the process of tailoring the global HIV/AIDS practice guidelines for use in developing countries.
  43. (2001). Evidence Based Medicine (CEBM): Levels of evidence.
  44. (2004). Evidence based medicine and ethics: a practical approach.
  45. (2004). ExTraMATCH Collaborative: Exercise training meta-analysis of trials in patients with chronic heart failure (ExTraMATCH). BMJ
  46. (2004). Foundation for Medical Research (AHFMR): B-type natriuretic peptide for diagnosing congestive heart failure.
  47. (2002). Foundation of Australia and Cardiac Society of Australia & New Zealand: Guidelines on the contemporary management of the patient with chronic heart failure in Australia.
  48. (2000). FW: [Determining priorities in the development of medical guidelines. 1: Criteria, procedures and actors: a methodological review of international experiences]. Z Arztl Fortbild Qualitatssich
  49. (2003). G: A consensus process to adapt the World Health Organization selected practice recommendations for UK use. Contraception
  50. (2003). General Practitioners' Guideline Group of Hessen: [Guideline report of the Guideline Group of Hessen – general practice therapy circle: management of chronic heart failure]. Z Arztl Fortbild Qualitatssich
  51. (2006). German Society for General Practice and Family Medicine. Guideline No. 9 'Heart Failure'. Duesseldorf: Omikron Publishing;
  52. (2003). Gibis B: [Liquid-based slide preparations and automated devices in examining cervical smears – systematic review of medical efficacy and health economics, and decision analysis].
  53. (1995). Grey zones of clinical practice: some limits to evidence-based medicine. Lancet
  54. (2004). Group: Grading quality of evidence and strength of recommendations. BMJ
  55. (1999). Guidance: what role should consensus play in guideline development? In Making use of guidelines in clinical practice Edited by:
  56. (2008). Guideline adaptation: an appealing alternative to de novo guideline development. Ann Intern Med
  57. (2001). Guidelines for the diagnosis and treatment of chronic heart failure.
  58. (1998). Guidelines on anticoagulant treatment in atrial fibrillation in Great Britain: variation in content and implications for treatment. BMJ
  59. (2000). GW: Dementia diagnostic guidelines: methodologies, results and implementation costs.
  60. (2002). Health care systems: Germany and Britain compared. Health care delivery – towards an agenda for policy learning between Britain and Germany.
  61. (1993). Health technology and its assessment.
  62. (2004). IA: The impact of guidelines on mild hypertension in pregnancy: time series analysis. BJOG
  63. (2002). ID: The process of developing best practice guidelines for nurses in Ontario: risk assessment and prevention of pressure ulcers. Ostomy Wound Manage
  64. (2003). Implicit normativity in evidence-based medicine: a plea for integrated empirical ethics research. Health Care Anal
  65. (2000). Jr: Developing clinical practice guidelines for heart failure: creative process and practice implications. Pharmacother
  66. (2001). Kommission Klinische Kardiologie: [Guidelines for the treatment of chronic heart failure. Issued by the Executive Committee of the German Society
  67. (2001). Leitlinie Diagnose und Therapie der chronischen Herzinsuffizienz.
  68. (2006). LM: Accuracy of B-type natriuretic peptide tests to exclude congestive heart failure: systematic review of test accuracy studies. Arch Intern Med
  69. (2003). Major depressive disorder in the general hospital: adaptation of clinical practice guidelines. Gen Hosp Psychiatry
  70. (2007). Majumdar SR: How evidence-based are the recommendations in evidencebased guidelines? PLoS Med
  71. (2008). Market justice and US health care. JAMA
  72. (2005). MB: Evaluation and adaptation of clinical practice guidelines. Evid Based Nurs
  73. (2007). Medical professionalism in a commercialized health care market. JAMA
  74. (2002). Muris JW: Evaluation of diagnostic procedures.
  75. (1999). N: Guidelines in professions allied to medicine. The Cochrane Database of Systematic Reviews
  76. (2006). OECD Health Equity Research Group. Income-related inequality in the use of medical care in 21 OECD countries. Towards high-performing health systems: policy studies 2004:109-66 [http://www.oecd.org].
  77. (2006). on behalf of the COST B13 Working Group on Guidelines for the Management of Acute Low Back Pain in Primary Care, et al.: European guidelines for the management of acute nonspecific low back pain in primary care.
  78. (2000). Ontario Program for Optimal Therapeutics: Ontario drug therapy guidelines for chronic heart failure in primary care.
  79. (2003). Pharmacologic management of heart failure and left ventricular systolic dysfunction: Effect in female, black, and diabetic patients, and cost effectiveness. Evidence Report/Technology Assessment No.
  80. (2003). PT: Entscheidungsgrundlage zur evidenzbasierten Diagnostik und Therapie bei Disease Management Programmen für Herzinsuffizienz bei systolischer linksventrikulaerer Dysfunktion.
  81. (1995). RSA: The wellbuilt clinical question: a key to evidence-based decisions.
  82. (2003). SN: Comparing methodological quality and consistency of international guidelines for the management of patients with chronic heart failure.
  83. (2003). The AGREE Collaboration: Appraisal of Guidelines for Research & Evaluation (AGREE) instrument training manual.
  84. (2003). The AGREE Collaboration: Development and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: the AGREE project. Quality and Safety in Health Care
  85. (2006). The Canadian Hypertension Education Program (CHEP) – A unique Canadian initiative.
  86. (1999). The DEGAM-concept – development, dissemination, implementation and evaluation of guidelines for general practice. [German] Z Arztl Fortbild Qualitatssich
  87. (2004). The Finnish Medical Society Duodecim: Chronic heart failure.
  88. (2008). The meaning of translational research and why it matters. JAMA
  89. (2003). The National Collaborating Centre for Chronic Conditions: Chronic heart failure. National clinical guideline for diagnosis and management in primary and secondary care.
  90. (2001). The National Heart Foundation of New Zealand: A guideline for the management of heart failure.
  91. (2001). Use of systematic review in clinical practice guidelines: case study of smoking cessation. BMJ
  92. (1999). Using clinical guidelines. BMJ
  93. (2003). Using socioeconomic evidence in clinical practice guidelines. BMJ
  94. (2003). Utility of the aminoterminal fragment of pro-brain natriuretic peptide in plasma for the evaluation of cardiac dysfunction in elderly patients in primary health care. Clin Chem
  95. (2002). What is clinical effectiveness?
  96. (2006). Winslade WJ: Clinical ethics. A practical approach to ethical decisions in clinical medicine. 6th edition.
  97. (2001). Woolf SH: Validity of the Agency for Healthcare Research and Quality clinical practice guidelines: how quickly do guidelines become outdated? JAMA
  98. (2001). Woolf SH: When should clinical guidelines be updated? BMJ

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