When recommendations emerge from consensus opinion, these often emanate from strongly held and sometimes diverse views giving some substance to the perspective of Abba Eban, former Israeli Ambassador to the United Nations, who suggested that “consensus means that lots of people say collectively what no one believes individually”. Approximately 25 such guidelines have emerged since the ACC/AHA commenced joint production of these in 1980 making it difficult to stay abreast of the volume of recommendations. Indeed, as recently reported by Ohman and Peterson, even within the three guidelines for ischaemic heart disease encompassing chronic stable angina, unstable angina, and acute myocardial infarction (which are frequently updated), there are a total of 462 recommendations.3
Such a litany of options underscores the need for the emergence of critical pathways and care maps that translate such guidelines into practical tools and protocols detailing specifically how the process of care should unfold as tailored to individual institutions.4
These are especially useful in high volume, procedure related activities and medical conditions that consume substantial resources. Commonly, in cardiovascular disease, they have been applied to patients with acute ST segment elevation myocardial infarction as it relates to the use of fibrinolysis and percutaneous coronary intervention, and the early management of patients with chest pain in chest pain units and/or observation areas.
The European Society of Cardiology and Canadian Cardiovascular Society have been similarly active in the development of guidelines and there is strong impetus for international collaboration. To the extent it is feasible, harmonisation of such guidelines in order to make the best use of evolving data and opinion is most desirable. Agreement across countries and even continents may well be achieved by a community of experts and professional societies, but the challenges around implementation may well impede their effectiveness. Hence, the number of available expert providers, their system of remuneration, the health care system(s) in which they work, and the distribution of technologically advanced facilities across diverse geographical terrains poses substantial challenges.
In 1989 the Agency for Health Care Policy and Research (AHCPR) was created to “enhance the quality, appropriateness and effectiveness of health care services through the establishment of a broad base of scientific research and through the promotion of improvements in clinical practice in any organization financing and delivering health care services”.5
Part of their charge was to develop guidelines. In order for this agency to fulfil its mandate the Institute of Medicine convened an advisory committee which issued a report in 1990 within which practice guidelines were defined as “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances”.6
In a 1994 document developed by the Canadian Medical Association derived from a workshop of 40 health care organisations who formulated six background research papers, a statement of guidelines for Canadian clinical practice guidelines was developed according to three categories: philosophy and ethics, methods and implementation, and evaluation.7
From the philosophical and ethical perspective it was perceived that the goal of guidelines should be to improve the quality of care enabling informed decision making between patients and well prepared physicians who discharge their primary responsibility to their patients in an ethical framework. A methodology was articulated concerning the need for a clear statement of goals by physicians in collaboration with other health care providers and patients as appropriate. The nature, strength, and timeliness of the evidence supporting the guidelines were to be cited and external review by appropriate experts and user groups undertaken before implementation. A standard format for on-line abstract publication with the National Library of Medicine in the USA was developed and the effectiveness after implementation, user feedback and a strategy for review and revision was suggested as an important component to incorporate.8
Guideline recommendations: classification
- Class I: general agreement that a procedure or treatment is useful and effective
- Class II: conflicting evidence or divergence of opinion exists
- Class IIa: weight of evidence or opinion favours utility or efficacy of procedure or treatment
- Class IIb: weight of evidence or opinion is less well established
- Class III: evidence or general agreement that the procedure or treatment is either not useful or effective or in some cases may be harmful
Some have argued—for example, the American College of Emergency Physicians (ACEP)—that guidelines consist of detailed or expanded lists that are meant to prompt physicians to consider actions that should be modulated by individual patients, their circumstances, and other factors.9
Their premise is that guidelines are not always followed and that there is no implication that failure to follow them is improper. Although this approach would be too lenient for many, the ACEP goes on to distinguish guidelines from rules which are defined as actions “reflecting principles of good practice in most situations. There may be circumstances when a rule need not or cannot be followed; in these situations it is advisable that deviation from the rule be justified in writing. Inability to comply with rules should be incorporated in institutional policies”.