Remarkable differences between three evidence-based guidelines on management of obstructive sleep apnea-hypopnea syndrome

Adapting clinical guidelines in low-resources countries: a study on the guideline on the management and prevention of type 2 diabetes mellitus in Indonesia

RATIONALE, AIMS AND OBJECTIVES

Most of the clinical guidelines in low-resource countries are adaptations from preexisting international guidelines. This adaptation can be problematic when those international guidelines are not based on current evidence or original evidence-based international guidelines are not followed. This study aims to evaluate the quality of an Indonesian type 2 diabetes mellitus guideline adapted from selected international guidelines.

METHODS

The "Consensus on the Management and Prevention of type 2 Diabetes in Indonesia 2011" is a guideline by the Indonesian Society of Endocrinology (Perkeni). Four parent guidelines identified from its list of references were from the International Diabetes Federation (IDF), American Association of Clinical Endocrinologist (AACE), American Diabetes Association (ADA), and one jointly released by ADA and European Association for the Study of Diabetes (EASD). Two reviewers independently assessed its quality using the Appraisal of Guidelines, Research and Evaluation Collaboration (AGREE II) instrument. Six recommendations were compared: (1) screening for diabetes; (2) diagnosis; (3) control of hyperglycemia; (4) target blood glucose; (5) target blood pressure; and (6) treatment of dyslipidemia.

RESULTS

Perkeni's guideline satisfied 55% of the AGREE II items, while its parent guidelines satisfied 59% to 74%. Perkeni's shows low score on "rigor of development" and "applicability" and the lowest score in the "scope and purpose" domain. Differences were found in 4 recommendations: the screening of diabetes, control of hyperglycemia, target blood glucose, and treatment of dyslipidemia. In 3 of 4, Perkeni followed the ADA's recommendation.

CONCLUSION

Derivation of recommendations from parent guidelines and their adaptation to the context of Indonesian health care lacks transparency. When guidelines are either derived from other guidelines or adapted for use in different context, evidence-based practice principles should be followed and adhered to.

Who Wrote This Clinical Practice Guideline?

The American Academy of Otolaryngology-Head and Neck Surgery Foundation clinical practice guidelines address a variety of otolaryngologic diseases and/or procedures. It may seem reasonable to create these guidelines by assembling a team of expert clinicians familiar with the pertinent clinical issues and the available evidence, with debate and eventual agreement leading to recommendations. However, trustworthy clinical practice guidelines are in fact created via a defined process to assemble a guideline development group composed of diverse stakeholders: clinician generalists and specialists, content experts, methodologists, physicians and nonphysicians, patients, and advocates. Such a guideline development group can create a valuable and trusted guideline for clinicians and affected patients.

Nonconformity in the clinical practice guidelines for subclinical Cushing's syndrome: which guidelines are trustworthy?

OBJECTIVE

This study aimed to systematically evaluate the quality of clinical practice guidelines (CPGs) and to compare their recommendations for managing subclinical Cushing's syndrome (SCS) to assist practitioners in making rapid clinical decisions.

DESIGN AND METHODS

SCS management guidelines were retrieved from electronic databases. The Appraisal of Guidelines Research and Evaluation II (AGREE-II) tool and the Institute of Medicine (IOM) criteria were used to evaluate the quality of the selected guidelines. In addition, we further compared recommendations, cited references and levels of evidence between the SCS management guidelines.

RESULTS

We included five guidelines that were obtained through the literature selection process. On the basis of the AGREE-II and IOM criteria, none of the selected guidelines were satisfactory in all aspects. However, the Italian Association of Clinical Endocrinologists (IACE) guidelines demonstrated slightly higher scores than did the other guidelines, so this guideline was recommended (with certain modifications for several domains). Regarding the content of the CPGs, we found considerable differences in the recommendations for managing SCS. These differences were derived from citation selection bias, evidence interpretation bias, differences in the composition of the guidelines' workgroups and the omission of guidelines for updating and externally reviewing the recommendations.

CONCLUSIONS

There is generally poor guideline quality among different organisations, and remarkable differences exist in the recommendations for the same clinical subject. Therefore, future guideline development should be performed in strict accordance with the AGREE-II and IOM criteria.

Update on management options in the treatment of nosocomial and ventilator assisted pneumonia: review of actual guidelines and economic aspects of therapy

Objective

Nosocomial or more exactly, hospital-acquired (HAP) and ventilator-associated pneumonia (VAP) are frequent conditions when treating intensive care unit (ICU) patients that are only exceeded by central line-associated bloodstream infections. In Germany, approximately 18,900 patients per year suffer from a VAP and another 4,200 from HAP. We therefore reviewed the current guidelines about HAP and VAP, from different sources, regarding the strategies to address individual patient risks and medication strategies for initial intravenous antibiotic treatment (IIAT).

Material and methods

We conducted an analysis of the recent guidelines for the treatment of HAP. The current guidelines of the American Thoracic Society, the treatment recommendations of the Paul-Ehrlich-Gesellschaft (PEG), the guidelines from the British Society for Antimicrobial Chemotherapy, the VAP guideline of the Canadian Critical Care trials group, as well as the new German S3-guideline for HAP were examined.

Results

All guidelines are based on grading systems that assess the evidence underlying the recommendations. However, each guideline uses different grading systems. One common aspect of these guidelines is the risk assessment of the patients for decision making regarding IIAT. Most guidelines have different recommendations depending on the risk of the presence of multidrug resistant (MDR) bacteria. In guidelines using risk assessment, for low-risk patients (early onset, no MDR risk) aminopenicillins with beta-lactamase inhibitors (BLI), second or third generation cephalosporins, quinolones, or ertapenem are recommended. For patients with higher risk, imipenem, meropenem, fourth generation cephalosporins, ceftazidime or piperacillin/tazobactam are recommended. The PEG recommendations include a combination therapy in cases of very high risk (late onset, MDR risk, ICU, and organ failure) of either piperacillin/tazobactam, dori-, imi- or meropenem or cefepime or ceftazidime with ciprofloxacin, levofloxacin, fosfomycin or an aminoglycoside. For the treatment of HAP caused by methicillin-resistant Staphylococcus aureus (MRSA), either linezolid or vancomycin is recommended. With regard to the ZEPHyR-trial, linezolid has shown higher cure rates but, no difference in overall survival. Economic analyses show the relevance of guideline-adherent IIAT (GA-IIAT). Besides significantly better clinical outcomes, patients with GA-IIAT cause significantly lower costs (€28,033 versus (vs) €36,139) (P=0.006) and have a shorter length of stay in hospital (23.9 vs 28.3 days) (P=0.022).

Conclusion

We conclude that most current treatment guidelines take into account the individual patient risk and that the correct choice of IIAT affects clinical as well as economical outcomes.

Clinical practice guidelines on the management of patients with common otologic pathology toward European consensus: outline of approach

OBJECTIVE

To achieve a European consensus about the best-evidence informed-management of patients with common otologic-related problems.

DESIGN

Consensus process, supported by the European Academy of Otology & Neuro-Otology.

SETTING

The European Academy of Otology & Neuro-Otology.

METHODS

A guideline of a specific disease should include evidence-informed recommendations about questions relating to treatment, prognosis, and diagnosis. A standardized method to design guideline questions to search for evidence and to grade the quality of available evidence results in an overview of the best available literature. Experts achieve a consensus on best practice and articulate recommendations on evidence-based actions to be taken in patient care accordingly. The assets of such evidence-based consensus usually are the opinion of experts and arguments on availability, transferability, applicability, and affordability.

DISCUSSION

The volume of new information increases at a staggering pace. As a result, there is an increasing demand for consistent systematic management of the available evidence. Systematic filtering of available evidence will help clinicians to find and apply best available and latest evidence efficiently and quickly.

CONCLUSION

Despite the otologic line of approach, the present article provides a step-by-step "guideline development instruction manual," which could be used within other medical specialties.