1. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 17 Clinical Practice Guidelines and Clinical Prediction Rules

2. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter Overview Difference between clinical prediction guides/rules and clinical practice guidelines. Understand the grading system for clinical practice guidelines. Concept and application of clinical prediction guides. Ottawa Ankle Rules used as prediction guides. Practice guides are connected to diagnostic studies. Patient care is improved through the use of clinical practice guidelines and clinical prediction guides. Concept of “strength of evidence” in clinical research. Outside influences when implementing a strategy to take care of a patient.

3. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Clinical Prediction Guides as Evaluative Procedures Clinical prediction guides/rules are developed from a cluster of exam findings or characteristics. They assist in the evaluative or treatment phase of patient care. The Ottawa Ankle Rules are an example of a clinical prediction guide that has evolved into a clinical practice guideline. –The Ottawa Ankle Rules are based on the observation of weight-bearing status and areas of tenderness upon palpation. Clinical prediction guides for the use of radiographic examination: for patients with knee pain and a history of cervical spine injury. Clinical prediction guides assist in indentifying conditions in which single examination procedures provide unacceptable results and “gold standard” assessment is difficult.

4. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Data Analysis Data analysis can compare outcomes measures between groups in studies conducted to develop clinical predication guides. Data analysis conducted in preparation of a guide can generate likelihood ratios. Cleland, Childs, Fritz, Whitman, & Eberhart (2007) Example: –Identifying patients with neck pain likely to benefit from thoracic spine manipulation. Clinical prediction guides are single research endeavors that provide estimates of population values. Repetition of studies: when similar results are reported in other studies, the prediction guide is strengthened and point estimates can be refined through meta-analysis.

5. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Practice Guidelines vs. Clinical Prediction Guides Practice guidelines and prediction guides assist in the diagnosis and treatment of patients. Guidelines are developed by a team of clinician-scholars after systematic review of the literature rather than from a single investigation and are generally more comprehensive than prediction guides. Clinical practice guidelines are systematically developed statements that help the practitioner and patient decide on the appropriate health care for specific clinical circumstances. The task of authors of clinical practice guidelines (position statements) is to synthesize the best available evidence and provide concise recommendations for patient care.

6. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins A Word of Caution: Clinical Practice Guidelines Clinical practice guidelines can provide a quick reference for a course of action in the evaluation and treatment of a particular patient. Clinical practice guidelines are likely to offer direction. The evidence behind a clinical practice guideline is derived from the review of one or more systematic reviews or from expert consensus. The strength of the evidence should be provided to the consumer for each component of a guideline. System of grading recommendations: –Uses letters A, B, C, and D based on the strength of the research evidence available.

7. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Level of Evidence and Grade of Recommendation Grade A recommendations are the result of the availability of level 1 evidence ( a “–” is added to identify recommendations where there is concern resulting from heterogeneity of findings or wide confidence intervals). Grade B recommendations stem from systematic reviews based on level 2 evidence consisting of systematic reviews of cohort studies. Grade C recommendations are based on case series or lower quality case control studies or cohort studies (evidence level 4). Grade D recommendations stem from expert opinions, logical applications of physiological principles, or bench science (evidence level 5).

8. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Diagnostic Practice Guidelines and Grades of Recommendation Diagnostic Practice Guidelines Grade A recommendations result from systematic reviews of high-quality diagnostic studies. Grade B recommendations result from systematic review of diagnostic studies in which one or more sources of bias were introduced (e.g., not all patients received the “gold standard” assessment, assessors were not blinded, etc.). Grade C recommendations stem from single clinical trials without assessor blinding (evidence level 4). Grade D recommendations are the result of expert opinion, logical applications of physiological principles, or bench science (evidence level 5). (A “–” is used to signify that there is concern resulting from heterogeneity of findings or wide confidence intervals.)

9. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Additional Considerations In the case of prevention efforts, one must decide if the event rate and/or seriousness of the problem warrant the expenditure and effort required to implement the intervention. When a patient is able to provide input, one must consider whether a proposed plan for diagnosis or treatment is in conflict with patient’s beliefs and values. One must consider if there are barriers to implementation. Organizational rules, entrenched local traditions, and resource availability may pose barriers the clinician cannot overcome when trying to implement a clinical practice guideline.

10. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter Overview and Key Points Clinical prediction guides are formed from a cluster of exam findings and may help in forming a diagnosis or planning the treatment of a patient. Position statements are often clinical practice guidelines developed to improve health care practice. The goal of clinical practice guidelines is to combine the best evidence and provide the most useful recommendations for patient care. Clinical practice guidelines should be regularly updated to reflect the best evidence to date. Clinical prediction guides can help in identifying a problem when a single examination does not provide results. Clinical prediction guides can be used to help determine the need for referral for radiographic examination and other diagnostic work-ups. Clinical practice guidelines are professional edicts developed by a team of clinician-scholars.