Manual for ACC/AHA Guideline Writing Committees
Methodologies and Policies from the ACC/AHA Task Force on Practice Guidelines
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Section II: Tools and Methods for Creating Guidelines
- Step Five: Synthesize and Interpret the Evidence
Recommendations:
The Essence of Guidelines
Steps One through Four describe the methodology
of guideline development as well as meta-analysis
and systematic review. Guideline development,
unlike the other methodologies, goes beyond the
compilation and analysis of data to include recommendations
that guide clinical practice. Guideline writers
are challenged with considering a vast array of
evidence and creating clinically applicable and
clear recommendations from it.
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It does not matter how much information you have or how valid and relevant it is, it should always be modulated by the values and preferences of the decision makers and those who will be affected by the decisions . . . In most cases, however, it will be unclear how much your anecdotal information, values and preferences should modulate the research evidence available. - Jadad, 1998 |
As the evidence is considered, conclusions and recommendations naturally evolve. Whenever this occurs, the recommendation should be condensed into a sentence or two and separated from the text (see Step Six). The recommendations are the core guideline content, while the text enhances the recommendations by providing further descriptive information, such as exceptions to the recommendations and clinical options.
If Step One determined that flow diagrams were appropriate, recommendations should be incorporated into the flow diagrams where appropriate (see Step Seven).
Because guidelines are increasingly serving as the basis for other ACC and AHA activities (such as pocket guides, performance measures, data standards, and GAP Projects), recommendations should be stand alone text that are written in complete sentences with as much detail as possible. Guidelines are intended to be applied by health care providers in real world settings, so the recommendations should be practical, feasible, and clinically flexible, thus facilitating the translation and implementation of recommendations.
Expert
Interpretation of the Evidence
ACC/AHA clinical practice guidelines are written
by cardiologists, other experts in the field of
cardiology or cardiovascular research, and representatives
from other organizations and specialties, when
relevant. Their scientific and clinical expertise
is germane to the creation of guideline recommendations
that are useful to a broad spectrum of health
care practitioners.
Despite all the evidence that may be available for writing the guideline, expert interpretation will always be necessary. Expert interpretation serves as a funnel through which evidence on multiple questions and clinical situations is combined, condensed, and formulated into recommendations.
Unfortunately, most evidence falls into the "gray zone" of uncertainty. The evidence from different trials may come to divergent conclusions, the evidence may only apply to specific sub-populations, the evidence may be from methodologically weak studies, or the evidence may simply be insufficient to make a decision. Only in rare instances is there an abundance of evidence available that leads directly to an indisputable recommendation.
Writing guidelines and formulating recommendations are not simple tasks. The guideline writer is frequently in a dilemma as to whether to delay making a decision or come to a conclusion despite the holes in the evidence. Checklist 4 (see below) in this section provides a list of qualities of guideline recommendations to consider when writing the document.
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Checklist 4. Writing Guideline Recommendations
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