February 4, 2013 — Few issues are more important to the American College of Cardiology (ACC) and the American Heart Association (AHA) than translating the best available scientific evidence into clinical practice guidelines that can be used by healthcare professionals to improve patient outcomes and the quality of cardiovascular care. This is evidenced by the 17 clinical practice guideline topics — and many more updates — the organizations have jointly developed and published since the early 1980s through a highly robust process and methodology that continues to evolve.
As part of ongoing efforts to improve the methodology behind these influential guidelines and to respond to two seminal Institute of Medicine (IOM) reports, “Clinical Practice Guidelines We Can Trust” and “Finding What Works in Health Care: Standards for Systematic Reviews,” the ACCF/AHA Task Force on Practice Guidelines held a two-day intensive Methodology Summit in mid-December 2011. Five workgroups were commissioned five months earlier to compare and contrast current methods against the standards set forth by the IOM as the ideal methods for developing trustworthy practice guidelines. The organizations released a summary of this analysis and proposed changes, including plans to incorporate patient representatives, manage intellectual and practice perspectives, expand peer review, and to conduct full systematic reviews as part of its already rigorous process.
“This was a natural next step in the evolution of our process and methods as we strive to integrate and respond to the continuous stream of new knowledge,” said Alice Jacobs, M.D., professor of medicine at Boston University School of Medicine and the immediate-past chair of the practice guidelines task force. “At the time the IOM report was released, we were already compliant with many of the proposed standards, but we used this as an opportunity to continue to improve.” In particular and for the first time, ACC and AHA will invite patient representatives — defined as patients and former patients, patient advocates or patient/consumer organization representatives — to participate as members of task force and guideline writing committees.
“We have practice recommendations that we know, when implemented, are associated with a reduction in mortality, but for those where the evidence is lacking, it becomes even more critical to involve patients and understand their preferences,” said Jacobs. “This is a real opportunity for us; it’s germane to both AHA and ACC and further reinforces our efforts to promote patient-centered care.”
In addition, the workgroups determined that the ACC/AHA guideline development process should expand to include a separate Evidence Review Committee tasked with the systematic review process. Jacobs said the ACC and AHA will begin to conduct and integrate full systematic evidence reviews initially using a focused approach to a confined topic and, when feasible, will collaborate with other organizations in this evidence review process.
Members of the workgroups were charged with looking at all 21 standards and 82 supporting elements from the IOM report. Each one is addressed in the current report. In the spirit of providing easy-to-use resources, summary tables are provided at the end of the report to detail the current methodology along with proposed changes.
“This was a major initiative for the Task Force and invited members of each workgroup. In addition, guests at the summit included those with expertise in biostatistics, methodology and guideline development,” said Jacobs. We worked together to address the gaps and barriers between our current guideline methodology and the proposed IOM standards, many of which were in complete alignment. We made recommendations to continue with [existing practices] or to implement changes that would enhance our current methods.”
Even before the IOM reports were released in March 2011, Jacobs says the ACC and AHA had instituted important changes that would later align with many of the IOM recommendations. Examples include introducing a focused update process to respond to new knowledge and revise existing guidelines more quickly and efficiently; incorporating feedback from the clinical community and other multidisciplinary stakeholders; limiting the amount of text to focus more on evidence and summary tables and enhance ease of use at the point of care; holding consensus conferences to vet recommendations across multiple guideline committees to ensure consistency, and developing a quality evidence scoring tool for randomized clinical trials.
Together, the ACC and AHA jointly oversee guidelines that focus on specific cardiovascular conditions. Once developed, peer reviewed and approved by all partnering organizations, these guidelines have been vetted throughout much of the academic and clinical community and, once jointly published in the Journal of the American College of Cardiology and Circulation, they serve as official policy of the organizations, informing strategic initiatives, advocacy, education and services.
The full report, “ACCF/AHA Clinical Practice Guideline Methodology Summit Report” was published in the Jan. 15 issue of the Journal of the American College of Cardiology and will be accessible on the ACC web site. It will also be published online in the American Heart Association journal Circulation.
For more information: www.cardiosource.org