The Development, Use, and Limitations of Standards, Guidelines, and Best Practices

Educational Objectives

The goal of this program is to improve the use and understanding of practice guidelines. After hearing and assimilating this program, the clinician will be better able to:

1. Consider the roles and limitations of guidelines.

2. Define terms related to the development and implementation of guidelines.

3. Tailor guideline recommendations according to the needs of the individual patient.

Summary

Background: multiple different guidelines often apply to any given situation; impulse exists to create standardized practices to address same problems with same procedures in same manner every time, but every patient is different

Clinical practice guidelines: Institute of Medicine — states that intent of guidelines is to optimize patient care; involves systematic review of evidence and assessment of benefits and harms of alternative options for care; UpToDate article — defines guidelines as recommendations for care; emphasizes that guidelines should be based on available research evidence plus practice experience

Historical factors: federal agency called Agency for Healthcare Research and Quality embarked on mission to develop guidelines in 1980s; agency had observed that different practices were being followed in different parts of country without clear reasons; goal to standardize practices across different regions of country to reduce adverse events and improve quality of care; one definition of quality, derived from industrial production, deals directly with variation; minimizing variation important for industrial production; less applicable to health care, but decreasing variation remains among goals of guidelines; following or failing to follow guidelines has implications for malpractice and other legal concerns; third-party payers, including Centers for Medicare and Medicaid Services, have guidelines that determine reimbursement; speaker states that point of guidelines should be to improve care of patient; whether or not they achieve that result should be measure of their usefulness

Terms: “standard” used infrequently because of implication of “standard of care,” with its medicolegal implications; more commonly used terms include advisory, alert, expert opinion, best practice, and recommendation; no precise and universally agreed upon definition for any term besides “standard;” multiple terms arise because of legal implications, regulatory implications, and reasons related to processes

Legal implications: attempts have been made by some states to make guidelines protective against malpractice claims if followed, and to disallow failure to follow guidelines to be used against health care professionals; such measures vehemently opposed by trial attorneys; lawyers often disagree on definitions of terms and their legal implications; legal issues often come down to adequacy of documentation; following guidelines does not provide universal protection against litigation

Where to find guidelines: GuidelineCentral website (https://www.guidelinecentral.com/) has many, but not all, guidelines; ECRI Institute (https://www.ecri.org/) attempting to include many guidelines on website; Medscape (https://www.medscape.com/today) has many guidelines; specialty societies publish their own guidelines; Canadian Anesthesiologists’ Society website (https://www.cas.ca/en/home) among best sources for finding many guidelines in one place

American Society of Anesthesiologists (ASA): produces many documents under many different classifications; different classifications determined by process for approval in many cases; guidelines, advisories, and alerts start with committee and approved by ASA Board of Directors and House of Delegates; House of Delegates and/or Board of Directors can change some classes of document, and others simply approved or not approved; different set of ASA documents called “Resources from ASA Committees” not approved by Board of Directors or House of Delegates and explicitly do not represent ASA policy; ASA Perioperative Brain Health Initiative (https://www.asahq.org/brainhealthinitiative) provides resources on perioperative brain protection; set of best practices developed by task force sponsored by ASA, evidence-based, and reached through consensus, but have not gone through formal approval process by ASA, so maintained in separate category

Canadian Anesthesiologists’ Society: maintains set of general guidelines for practice of anesthesia (https://www.cas.ca/en/practice-resources/guidelines-to-anesthesia); appendix contains references to guidelines from various specialty societies; simple list (not hyperlinked)

Development process: systematic review of evidence conducted to determine strength of evidence, then expert consensus formed based on evidence; designated experts develop set of recommendations based on evidence and experience; system imperfect and evolving; guidelines for developing guidelines currently exist; development process should be transparent in terms of personnel involved and potential conflicts of interest; conflicts of interest often unavoidable, but necessary to declare them; recommendations require review by external body and updates on regular basis

Evaluation of guidelines: guidelines should show transparency about personnel involved in writing original guidelines and updates, strength of evidence used to formulate guideline, and specific topics addressed by updates

Caring for individual patient: guidelines sometimes conflict; terms sometimes defined differently by different guidelines; many guidelines do not address multiple comorbidities; speaker urges consideration of individual patient’s best interests; primary goal to care for patient (as opposed to adhere to guideline)

Artificial intelligence (AI): AI can be used to generate perfect predictions for historical dataset; does not work as well on future datasets; theoretical idea to leverage AI and machine learning to assess outcomes in large datasets and individualize information for each patient; resultant algorithm likely “black box” understood by machine but not necessarily by clinician; human cannot necessarily understand algorithm generated by computer; debatable whether clinicians willing to accept decision of AI if algorithm incomprehensible

Question and Answer

Enhanced Recovery After Surgery (ERAS): audience comment — ERAS involves standardization for multiple different procedures; studies supporting ERAS all involved colorectal and cardiothoracic surgery, but institutions now adopting these standardized practices for multiple procedures; anesthesia professionals feeling pressure from surgeons to perform anesthetic based on “arbitrary” ERAS protocols; Dr. Poterack — represents good example of attempting to apply practice that has good evidence for specific group of patients to other groups; external pressures present real concern

Readings

American Society of Anesthesiologists Perioperative Brain Health Initiative: https://www.asahq.org/brainhealthinitiative. Accessed July 10, 2019; American Society of Anesthesiologists standards and guidelines: https://www.asahq.org/standards-and-guidelines. Accessed July 10, 2019; Canadian Anesthesiologists’ Society. https://www.cas.ca/en/home. Accessed July 10, 2019; Canadian Anesthesiologists’ Society guidelines to the practice of anesthesia, revised edition 2019: https://www.cas.ca/en/practice-resources/guidelines-to-anesthesia. Accessed July 10, 2019; ECRI Institute: https://www.ecri.org/. Accessed July 10, 2019; GuidelineCentral: https://www.guidelinecentral.com/. Accessed July 10, 2019; Medscape: https://www.medscape.com/today. Accessed July 10, 2019.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Poterack was recorded at the International Anesthesia Research Society 2019 Annual Meeting and International Science Symposium, held May 17-20, 2019, in Montreal, QC, and presented by the International Anesthesia Research Society. For information about upcoming CME opportunities from the International Anesthesia Research Society, please visit www.iars.org. The Audio Digest Foundation thanks the speakers and the International Anesthesia Research Society for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

AN613501

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.