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 2: The Review

In last week's Practice Perfect, I started to make the argument that our clinical practice guidelines in podiatry do not satisfy the purposes for which they were created. I identified the purpose and general characteristics of a practice guideline and proposed a basic method to evaluate them. This week, the rubber hits the road. Will our representative sample pass muster? Let’s see…

First, let me reiterate a point I made last week. I have great respect for those podiatric physicians who clearly took much time, effort, and leadership to create our guidelines. They should receive commendations for their excellent work, and the guidelines themselves have value and should be on all of our shelves. I will attempt to show that our guidelines, though well written and important, need to be rewritten to make them more evidence-based and more effective.

Ok. Let’s get to it.

I examined three published podiatric clinical practice guidelines, all three published in the Journal of Foot and Ankle Surgery:

1. Forefoot Trauma Guidelines¹
2. Adult Flatfoot Guidelines²
3. Diabetic Foot Disorders Guidelines³

For comparison, I also examined one non-podiatric guideline that pertains to the lower extremity:

• Peripheral Arterial Disease Guidelines⁴

Tonight's Premier Lecture is Diabetic Neuropathy by Aaron Vinik, MD, FACE, FACP, FCP, PHD

Using the checklist I presented last week, I evaluated each of the guidelines. Follow this link for the Appendix that shows the checklist results. According to my examination, the forefoot trauma and adult flatfoot guidelines almost completely failed to adequately satisfy the chosen criteria with a “Yes” answer in only 2 of 15 characteristics. The diabetic foot guidelines did a little better with 4 of 15 characteristics answered with a “Yes.” In comparison, the PAD guidelines satisfied 15 of 15 characteristics. All three podiatric guidelines failed to provide adequate information about the development group, formulate a stated consensus based on a systematic evaluation of the literature, or demonstrate appropriate peer review.

According to my review using a modified evaluative method from previously published guidelines, the current ACFAS podiatric clinical practice guidelines do not satisfy validity criteria. I noted several trends consistent through these guidelines. Significantly, none of our guidelines state that they use of a systematic approach for evaluating the literature or grading the strength of the evidence. Comparing our guidelines with the PAD guideline demonstrates this stark difference. Shown below in Table below is the classification used for evaluating the evidence regarding PAD).⁴ This method is quite common throughout general medical profession. Unfortunately, there is not even a hint of this type of analysis in our guidelines. The end result of this lack of a systematic evaluation is that our guidelines are essentially topic reviews rather than actual statements of consensus regarding a particular disease. 

Follow this link, or click on the table below for a larger view.

The ACFAS guidelines should more appropriately be titled “clinical pathways”.  They each present an algorithmic approach to diagnosis and treatment of their respective diseases. They do not describe any evaluative process of the best research with the intent to make specific “statements” about how these diseases should be treated. For example, while describing the various physical examination methods for the adult flatfoot, the guidelines do not evaluate the appropriateness of these techniques. There is, for instance, no discussion about the inter-rater reliability or even accuracy of these tests. When describing surgical options, they list the various procedures, but never make a “consensus statement” that such-and-such procedure is most appropriate. They don’t state if any particular method, such as using the concept of planal dominance to choose procedures, should be the accepted norm. There is no actual consensus opinion.

Now, there are several limitations to this discussion. First, I am one individual reviewing these guidelines, which adds potential bias to the analysis. Second, my review is far from systematic. For example, I reviewed 4 out of many practice guidelines. I would argue, though, that if you were to look at all of the podiatric-related guidelines, the same problems would be evident.

Additionally, as many others have pointed out about podiatric and orthopedic research, very little high quality literature on the foot and ankle exists on which to base these guidelines. The authors of our guidelines, therefore, had limited quality evidence to work with. I can only imagine what these clinical practice guidelines would look like if the authors had included only high quality research. There probably wouldn’t be much to criticize.

I propose two actions occur in the future. First, we change the titles of our documents to something like “clinical practice pathways.” Second, we rewrite the “guidelines” to better compare with those guidelines created by the rest of the medical community. Until then, we’ll have to be satisfied with excellent review articles.

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]

References

1. Thomas J, et al. Diagnosis and Treatment of Forefoot Disorders. Section 5. Trauma. JFAS, Mar 2009; 48(2): 264-272.
2. Lee M, et al. Diagnosis and Treatment of Adult Flatfoot. JFAS, March 2005; 44(2): 78-113.
3. Frykberg R, et al. Diabetic Foot Disorders: A Clinical Practice Guideline (2006 Revision). JFAS, Sept 2006; 45 (5): S1-S66.
4. Olin J, et al. ACCF/AHA/ACR/SCAI/SIR/SVM/SVN/SVS 2010 Performance
   Measures for Adults With Peripheral Artery Disease. Circulation, Dec 2010; 122: 2583-2618.

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