Including practice data to improve evidence-based guidelines. Example of guidelines on the management of thyroid nodules

Thyroid fine needle aspiration: how to improve clinicians' confidence and performance with the technique

Studies from single institutions report an acceptable accuracy rate for thyroid fine needle aspiration (FNA). However, FNA accuracy is much lower in many other centers in Europe and the USA and large multicenter studies indicate that the clinicians' confidence in the FNA technique remains low. One explanation for this is that there is an excess of inadequate and indeterminate findings for a follicular nodule at FNA cytology. In a University Hospital with large and qualified experience on thyroid nodule diagnosis, a review of 320 slides with an FNA diagnosis of indeterminate follicular nodule from different minor Italian Hospitals led to a different diagnosis in 61%. Since ancillary thyroid imaging may be overutilized and only a few authors report a proportion of excised nodules lower than 10%, we suspect that use of the FNA procedure is suboptimal. Several techniques are reported to improve the performance of thyroid FNA. Among these are tumor markers and large needle aspiration biopsy (LNAB). Immunodetection of the tumor marker galectin-3 has been evaluated by large multinational studies. Analysis of LNAB specimens reduces the number of inadequate FNA findings, improves the diagnostic determination of indeterminate follicular FNA findings and represents a better substrate for the determination of galectin-3. Therefore, we propose that clinical practice guidelines reflect these adjuvant techniques to thyroid FNA in order to improve selection criteria for thyroid nodule surgery.

Overview of health technology assessment in France

Health technology assessment (HTA) in France covers a variety of activities performed for different customers (e.g., health professionals in the field and policy makers in government) for the benefit of patients. To promote the improvement of quality in health care, France has set up a series of distinct agencies that report to the Ministry of Health but are also accountable to their other customers. We place particular emphasis on ANAES (National Agency for Accreditation and Evaluation in Health) whose main remit is HTA. We show how the diversity of HTA activities and their decentralization suggests tight collaboration among all the different bodies which perform HTA or are closely involved with HTA, and we provide examples of such collaboration.

Development and use of evidence-based clinical practice guidelines for thyroid disease

Clinical practice guidelines offer recommendations for optimizing health care. Guideline panels can rely on several methods for gathering information about current practice and synthesizing evidence that addresses specific questions. Clinical practice guidelines, including many that address thyroid disease, often rely on conventional narrative literature reviews and expert opinion rather than systematic evaluation of the published literature as the basis for their recommendations. This undermines the authority of practice guidelines and potentially results in disparate, invalid, or misleading recommendations. In contrast, incorporation of rigorous systematic reviews of literature and guidance by groups with multidisciplinary expertise decreases bias in evidence selection and increases precision of treatment effect estimates. Improved reliability and accuracy of evidence assessment, in turn, strengthens ultimate guideline recommendations. Cost-effective analyses further contribute to useful clinical practice guidelines and may encourage the explicit acknowledgment of values and preferences. Valid recommendations, however, prove futile in the absence of implementation. Adherence to guidelines may be improved with integration of user-friendly computer applications into clinical practice. By overcoming barriers to implementation and addressing the limitations of current guidelines, endocrinologists can play an essential role in improving the quality, efficiency, and cost-effectiveness of clinical practice related to thyroid disorders.

A method for guideline development: assessing practical feasibility and adaptation of thyroid nodule guidelines

The objective of this study was to assess adaptation and feasibility of practice guidelines for thyroid nodule management. For one month physicians completed a self-administered semi-structured questionnaire concerning a draft version of the guidelines for each consecutive patient. A sample group of 20 endocrinologists, 20 surgeons and 120 general practitioners from all parts of France took part in this study. The main outcome measures were whether the case description was found by the physicians, and whether recommendations were found and agreement with these recommendations were assessed. We found that two hundred and fifty-three patients (of whom 85% were women) were included in the study: 52% were seen for a surgical decision; 20% for diagnosis or screening and 28% for follow-up. Four percent of the women were pregnant; 2% of the patients had a large nodule; and 2%, a retrosternal nodule. These last three situations had not been well identified in the draft guidelines. The patient's case description was appropriately identified in 75% of the responses. Most cases reported as being not found were, however, covered by the guidelines. Physicians in private practice were less likely than the others to identify their patient's cases. Physicians agreed with the recommendation in 77% of cases. General practitioners were more likely and endocrinologists less likely than surgeons to disagree. Most disagreements and alternative proposals were not evidence-based. Our conclusion is that this study shows that the draft guidelines were applicable, and allowed minor improvements of the final version. Adapting guidelines to practice could improve their use and, consequently, the quality of health care.