September 26, 2013
Clinical Practice Guidelines Require Scrutiny for Quality
Allan S. Brett, MD reviewing Brito JP et al. J Clin Endocrinol Metab 2013 Aug. Reames BN et al. J Clin Oncol 2013 Jul 10.
Two studies revealed problems with endocrine and oncology guidelines.
In two critical evaluations, investigators have assessed the reliability of clinical
practice guidelines.
The first study concerned guidelines issued by the Endocrine Society, which uses the GRADE system (each recommendation is rated as strong or weak, and the quality of evidence supporting each recommendation is rated as high, moderate, low, or very low). Among 357 recommendations in 17 guidelines issued between 2005 and 2011, 121 (34%) combined a strong recommendation with low-quality evidence. Such guidelines require scrutiny because they strongly advocate a particular practice despite relatively weak supporting evidence. Using an explicit process, the authors found 33 instances in which no compelling justification for a strong-recommendation/low-evidence guideline existed.
In a second study, researchers reviewed 169 guidelines on prostate, lung, breast, and colorectal cancer published between 2005 and 2010. To determine whether guidelines were trustworthy, each was scored according to 8 standards published by the Institute of Medicine. On average, guidelines fulfilled only 2.75 of the 8 standards.
Comment
The proliferation of practice guidelines by professional societies, advocacy
organizations, and government agencies presents considerable challenges: They often conflict with each other, and as these two studies show, many are flawed. The analysis of Endocrine Society guidelines reminds me of one of the society's 2012 guidelines that I found problematic: a strong recommendation - despite low-quality supporting evidence - for glucose targets <140 mg/dL (premeal) and <180 mg/dL (random) for hospitalized patients with noncritical illness (J Clin Endocrinol Metab 2012; 97:16).
Editor Disclosures at Time of Publication
Citation(s):
Brito JP et al. The Endocrine Society guidelines: When the confidence cart goes before the evidence horse. J Clin Endocrinol Metab 2013 Aug; 98:3246.
(
http://dx.doi.org/10.1210/jc.2013-1814)
Abstract/FREE Full Text
Reames BN et al. Critical evaluation of oncology clinical practice guidelines. J Clin Oncol 2013 Jul 10; 31:2563. (
http://dx.doi.org/10.1200/JCO.2012.46.8371)
Abstract/FREE Full Text
