Are global guidelines desirable, feasible and necessary?

Applicability of European Society of Cardiology guidelines according to gross national income

AIMS

To assess the feasibility to comply with the recommended actions of ESC guidelines on general cardiology areas in 102 countries and assess how compliance relates to the country's income level.

METHODS AND RESULTS

All recommendations from seven ESC guidelines on general cardiology areas were extracted and labelled on recommended actions. A survey was sent to all 102 ESC national and affiliated cardiac societies (NCSs). Respondents were asked to score recommended actions on their availability in clinical practice on a four-point Likert scale (fully available, mostly/often available, mostly/often unavailable, fully unavailable), and select the top three barriers perceived as being responsible for limiting their national availability. Applicability was assessed overall, per World Bank gross national income (GNI) level, and per guideline.A total of 875 guideline recommendations on general cardiology was extracted. Responses were received from 64 of 102 (62.7%) NCSs. On average, 71·6% [95% confidence interval (CI): 68.6-74.6] of the actions were fully available, 9.9% (95% CI: 8.7-11.1) mostly/often available, 6.7% (95% CI: 5.4-8.0) mostly/often unavailable, and 11·8% (95% CI: 9.5-14.1) fully unavailable. In low-income countries (LICs), substantially more actions were fully unavailable [29·4% (95% CI: 22.6-36.3)] compared with high-income countries [HICs, countries 2.4% (95% CI: 1.2-3.7); P < 0.05]. Nevertheless, a proportion of actions with the lowest availability scores were often fully or mostly unavailable independent of GNIs. Actions were most often not available due to lack of reimbursement and other financial barriers.

CONCLUSION

Local implementation of ESC guidelines on general cardiology is high in HICs and low in LICs , being inversely correlated with country gross national incomes.

Endoscopic biopsy as quality assurance for endoscopic services

Gastroendoscopy (GS) procedures are not only performed by gastroenterologists (GE) but also by hepatologists (HT) in many countries. Endoscopic biopsy (EBx) remains the gold standard for the investigation and documentation of esophago-gastro-duodenal pathology. EBx is subjectively performed by an endoscopist, and the level of skill and experience of the endoscopist may affect the quality of the endoscopic service. Reasons for this discrepancy included lack of experience practitioners to order EBx when required of GS issues between in GE and HT limit access. Ideally, services should be safe and of high quality. This study assessed the EBx/GS ratio as the endoscopic quality assurance as an index of GS services. This was a cohort study of endoscopists at Kaohsiung Chang Gung Memorial Hospital, a teaching hospital in southern Taiwan. There were 34,570 episodes of EBx in 199,877 GS procedures. The 25 endoscopists were divided into GE (n = 13) and HT (n = 12) groups, and correlation coefficients were calculated over a 14.5-year duration of intervention. The Trimmean of EBx/GS was 19.29% in 14.5 years (34570/199877 with Trimmean 0.2 percentile ratio correlations), and the Pearson correlation coefficient was 0.90229. There were significantly more EBx procedures in the GE group than in the HT group at 1 and 5 years (21.5% vs. 15.1% and 20.9% vs. 17.3%, respectively, P<0.00001). Junior GE attempted significantly more EBx than both the senior GE (24.06% vs. 20.41%, P<0.0001), and junior HT (24.06% vs. 13.2%, P<0.0001). In conclusion, quality assurance for gastrointestinal endoscopy involves numerous aspects of unit management and patient safety. Quality measures used with the EBx/GS ratio may be one of the best ways to ensure the quality of endoscopic procedures in a teaching hospital.

Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)

OBJECTIVE

To develop a North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) international consensus on the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population.

METHODS

An international panel of 9 pediatric gastroenterologists and 2 epidemiologists were selected by both societies, which developed these guidelines based on the Delphi principle. Statements were based on systematic literature searches using the best-available evidence from PubMed, Cumulative Index to Nursing and Allied Health Literature, and bibliographies. The committee convened in face-to-face meetings 3 times. Consensus was achieved for all recommendations through nominal group technique, a structured, quantitative method. Articles were evaluated using the Oxford Centre for Evidence-based Medicine Levels of Evidence. Using the Oxford Grades of Recommendation, the quality of evidence of each of the recommendations made by the committee was determined and is summarized in appendices.

RESULTS

More than 600 articles were reviewed for this work. The document provides evidence-based guidelines for the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population.

CONCLUSIONS

This document is intended to be used in daily practice for the development of future clinical practice guidelines and as a basis for clinical trials.

Gastroenterology in developing countries: issues and advances

Developing countries shoulder a considerable burden of gastroenterological disease. Infectious diseases in particular cause enormous morbidity and mortality. Diseases which afflict both western and developing countries are often seen in more florid forms in poorer countries. Innovative techniques continuously improve and update gastroenterological practice. However, advances in diagnosis and treatment which are commonplace in the West, have yet to reach many developing countries. Clinical guidelines, based on these advances and collated in resource-rich environments, lose their relevance outside these settings. In this two-part review, we first highlight the global burden of gastroenterological disease in three major areas: diarrhoeal diseases, hepatitis B, and Helicobacter pylori. Recent progress in their management is explored, with consideration of future solutions. The second part of the review focuses on the delivery of clinical services in developing countries. Inadequate numbers of healthcare workers hamper efforts to combat gastroenterological disease. Reasons for this shortage are examined, along with possibilities for increased specialist training. Endoscopy services, the mainstay of gastroenterology in the West, are in their infancy in many developing countries. The challenges faced by those setting up a service are illustrated by the example of a Nigerian endoscopy unit. Finally, we highlight the limited scope of many clinical guidelines produced in western countries. Guidelines which take account of resource limitations in the form of "cascades" are advocated in order to make these guidelines truly global. Recognition of the different working conditions facing practitioners worldwide is an important step towards narrowing the gap between gastroenterology in rich and poor countries.

Systematic reviews: the good, the bad, and the ugly

Systematic reviews systematically evaluate and summarize current knowledge and have many advantages over narrative reviews. Meta-analyses provide a more reliable and enhanced precision of effect estimate than do individual studies. Systematic reviews are invaluable for defining the methods used in subsequent studies, but, as retrospective research projects, they are subject to bias. Rigorous research methods are essential, and the quality depends on the extent to which scientific review methods are used. Systematic reviews can be misleading, unhelpful, or even harmful when data are inappropriately handled; meta-analyses can be misused when the difference between a patient seen in the clinic and those included in the meta-analysis is not considered. Furthermore, systematic reviews cannot answer all clinically relevant questions, and their conclusions may be difficult to incorporate into practice. They should be reviewed on an ongoing basis. As clinicians, we need proper methodological training to perform good systematic reviews and must ask the appropriate questions before we can properly interpret such a review and apply its conclusions to our patients. This paper aims to assist in the reading of a systematic review.

A global, evidence-based consensus on the definition of gastroesophageal reflux disease in the pediatric population

OBJECTIVES

To develop an international consensus on the definition of gastroesophageal reflux disease (GERD) in the pediatric population.

METHODS

Using the Delphi process, a set of statements was developed and voted on by an international panel of eight pediatric gastroenterologists. Statements were based on systematic literature searches using Medline, EMBASE, and CINAHL. Voting was conducted using a six-point scale, with consensus defined, a priori, as agreed by 75% of the group. The strength of each statement was assessed using the GRADE system.

RESULTS

There were four rounds of voting. In the final vote, consensus was reached on 98% of the 59 statements. In this vote, 95% of the statements were accepted by seven of eight voters. Consensus items of particular note were: (i) GERD is present when reflux of gastric contents causes troublesome symptoms and/or complications, but this definition is complicated by unreliable reporting of symptoms in children under the age of approximately 8 years; (ii) histology has limited use in establishing or excluding a diagnosis of GERD; its primary role is to exclude other conditions; (iii) Barrett's esophagus should be defined as esophageal metaplasia that is intestinal metaplasia positive or negative; and (iv) extraesophageal conditions may be associated with GERD, but for most of these conditions causality remains to be established.

CONCLUSIONS

The consensus statements that comprise the Definition of GERD in the Pediatric Population were developed through a rigorous process. These statements are intended to be used for the development of future clinical practice guidelines and as a basis for clinical trials.

Can 'Cascades' make guidelines global?

Why are guidelines in medicine so important today? What role do they have? Why and how did the World Gastroenterology Organization (WGO) choose a global focus? What does this mean for guidelines? These are the underlying questions addressed by our article. We argue that the addition of 'Cascades' to guidelines will increase their impact in large parts of the world. By so doing, we hope to add a new dimension to the 'knowledge into action' debate. A number of illustrations shows how raised expectations and resource restrictions pose - or should pose - an enormous challenge for guideline makers. Furthermore, the emphasis on evidence also creates problems for guideline making. If resources are limited it is unlikely gold-standard technologies are available. We believe Cascades can help. A Cascade is a selection of two or more hierarchical diagnostic or therapeutic options, based on proven medical procedures, methods, tools or products for the same disease, condition or diagnosis, aiming to achieve the same outcome and ranked by available resources. The construction of such a cascade is a hazardous intellectual journey that goes, to some extent, against established practice. But lives can be saved by matching options for diagnosis and treatment to available resources. While the optimal strategy, defined through an evidence-based approach, should always be the goal, one must be aware of the resource limitations that confront our colleagues in certain parts of the world and we should endeavour to work with them in the guideline development process to develop strategies that are clinically sound yet economically feasible and dacceptable to their populace.