Jarrod Shapiro, DPM
Practice Perfect Editor
Assistant Professor,
Dept. of Podiatric Medicine,
Surgery & Biomechanics
College of Podiatric Medicine
Western University of
Health Sciences,
St, Pomona, CA

Podiatric Clinical Practice Guidelines: It’s Time for a Rewrite

Part 1: Purpose and Criteria

In today’s modern world of evidence-based medicine, one of the tools available to us is the clinical practice guideline. There’s a clinical practice guideline for every major disorder, whether it’s acute coronary syndrome, peripheral arterial disease, hypertension, asthma, or any of a number of other conditions. In podiatric medicine we too have clinical practice guidelines, including heel pain, diabetic foot disorders, 1st MTP joint disorders, pediatric flatfoot, and adult flatfoot, among others. We have one major problem, though, with our clinical practice guidelines: they are not useful for the purpose they were created. I’d like to recommend to our podiatric leaders that it’s time to rewrite our clinical practice guidelines.

I’ll make my argument in two parts. The first part will discuss the purpose of clinical practice guidelines and the criteria for evaluating them. In the second part, which we’ll get to next week, we’ll apply these criteria to a few of our major practice guidelines. We’ll see using these criteria that our guidelines are invalid for the purpose in which they were originally written.

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The Purpose

I’d like to say at the outset that I have great respect for those leaders who took the time and effort to create these guidelines. By no means are they invalid for all purposes, just those that are important from an evidence-based standpoint. At the very least, most of our guidelines are excellent general reviews of their respective topics, and I would suggest everyone in clinical practice read them.

Clinical practice guidelines have been in existence for a very long time. However, modern guidelines approach this from a standardized format that attempt to collate the best research and clinical evidence about the subject in question. These are essentially consensus statements about the best practices in medicine. Guidelines provide a tool for caregivers to understand the current standard of care (a controversial term in itself) for the diagnosis, prevention, and treatment of a specific disorder. I’ll state for clarity my personal opinion: the primary purpose of clinical practice guidelines should be to state and evaluate the best evidence in a systematic fashion to provide guidance to the average clinician on how he or she should diagnose and treat a specific disease.

The Criteria

Listed below in Table 1 is a modified and somewhat simplified approach to evaluating a clinical practice guideline.^1,2The criteria in Table 1 considers the following characteristics of quality clinical guidelines:²

Valid
Reproducible
Cost-effective
Representative
Clinically applicable

Flexible
Clear
Reviewable
Amenable to clinical audit

The criteria listed below will help us create a picture of the validity, appropriateness, and applicability of any particular clinical practice guideline. I think we’ll find once we apply this review checklist to most of the podiatric practice guidelines we’ll see just where the weaknesses lie. Significantly, when we compare the relative merits and drawbacks of our guidelines to other national guidelines, we’ll see in stark relief where the opportunities for improvement lie. Briefly, we’ll find that several of our clinical practice guidelines do not adequately synthesize the current research and, therefore, do not create consensus statements that are useful for the average practicing podiatric physician. Let the rubber hit the road!

Table 1. Evaluative method for clinical practice guidelines — modified from ^{1, 2}
Characteristic	Yes	No	Cannot tell
Guideline development group Is there a description of the individuals involved in development? Is there a statement of potential conflicts of interest of the panel members? Do the panel members appropriately represent the medical community of interest?
Evidence evaluation process Is there a systematic, well described process to evaluate the most current medical research? Were all important outcomes and options clearly discussed? Is there an explicit search strategy to gather the evidence? Was an explicit and sensible process used to grade the relative strength of the medical evidence?
Formulation of Recommendations Are practical, clinically important recommendations made? Is there an explicit link between the level of evidence and the recommendations? Does the document discuss the strength of the consensus recommendations?
Peer Review Have the guidelines been subjected to an appropriate and thorough peer review process? Have any potential limitations of the recommendations been discussed?
Applicability Are the recommendations applicable to patients in question? Are the guidelines clearly stated? Do the guidelines take patient values into consideration?

In our next issue, I’ll attempt to demonstrate the downfall of most of our clinical practice guidelines by evaluating specific ones using the method shown above and comparing them to other guidelines of high quality.

Keep writing in with your thoughts and comments. Better yet, post them in our eTalk forum.
Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

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References

Hayward R, et al. User’s Guide to the Medical Literature VIII. How to Use Clinical Practice Guidelines. A. Are the Recommendations Valid? JAMA, Aug 1995; 274(7): 570-574.
Broughton R and Rathbone B. What makes a good clinical guideline? Bandolier website; 1(11): 1-8. www.evidence-based-medicine.co.uk