This study, just published online in the Journal of General Internal Medicine, examined the quality of five guidelines covering various musculoskeletal disorders. The panel concluded that despite rigorous development, the quality of the published guidelines did not always meet their high standards.
Nuckols TK, Lim YW, Wynn BO, Mattke S, Maclean CH, Harber P et al. Rigorous development does not ensure that guidelines are acceptable to a panel of knowledgeable providers. J Gen Intern Med 2007 Nov 21; [Epub ahead of print]
BACKGROUND: Rigorous guideline development methods are designed to produce recommendations that are relevant to common clinical situations and consistent with evidence and expert understanding, thereby promoting guidelines’ acceptability to providers. No studies have examined whether this technical quality consistently leads to acceptability.
OBJECTIVE: To examine the clinical acceptability of guidelines having excellent technical quality.
DESIGN AND MEASUREMENTS: We selected guidelines covering several musculoskeletal disorders and meeting 5 basic technical quality criteria, then used the widely accepted AGREE Instrument to evaluate technical quality. Adapting an established modified Delphi method, we assembled a multidisciplinary panel of providers recommended by their specialty societies as leaders in the field. Panelists rated acceptability, including “perceived comprehensiveness” (perceived relevance to common clinical situations) and “perceived validity” (consistency with their understanding of existing evidence and opinions), for ten common condition/therapy pairs pertaining to Surgery, physical therapy, and chiropractic manipulation for lumbar spine, shoulder, and carpal tunnel disorders.
RESULTS: Five guidelines met selection criteria. Their AGREE scores were generally high indicating excellent technical quality. However, panelists found 4 guidelines to be only moderately comprehensive and valid, and a fifth guideline to be invalid overall. Of the topics covered by each guideline, panelists rated 50% to 69% as “comprehensive” and 6% to 50% as “valid”.
CONCLUSION: Despite very rigorous development methods compared with guidelines assessed in prior studies, experts felt that these guidelines omitted common clinical situations and contained much content of uncertain validity. Guideline acceptability should be independently and formally evaluated before dissemination.
- American Academy of Orthopaedic Surgeons. Guidelines and support documents for hip pain, knee injury, knee osteoarthritis, low back pain/sciatica, shoulder pain and wrist pain. 2001–2003.
- American College of Occupational and Environmental Medicine. Occupational Medicine Practice Guidelines: Evaluation and Management of Common Health Problems and Functional Recovery in Workers, Second Edition. Beverly Farms, Massachusetts; 2004.
- Intracorp. Intracorp Optimal Treatment Guidelines. Philadelphia, Pennsylvania; 2003.
- McKesson. InterQual Care Management Criteria for Workers’ Comp & Clinical Evidence Summaries. (Formerly QualityFirst® Workers’ Compensation/Disability Guidelines). Newton, Massachusetts. 2004.
- Work Loss Data Institute. Official Disability Guides (ODG), Treatment in Workers’ Compensation. San Diego, CA; 2004.