It may help to look into an important initiative on guideline standardisation here. This is one serious effort to support the process of improving guideline quality, as well as help point out the ones that lack it. Rather than pick on faults and chastise, it would create a situation wherein faults become unacceptable and evidence and quality necessarily the norm. Hence this initiative needs more than a cursory look.
A Conference on Guideline Standardisation (COGS) was convened in April 2002 ‘to define a standard for guideline reporting that would promote guideline quality and facilitate implementation
’ (Shiffman et al., 2003
Twenty-three people with expertise and experience in guideline development, dissemination and implementation participated. Representatives of 22 organisations active in guideline development reviewed the proposed items and commented favourably.
Closely related items were consolidated into 18 topics to create what they called the COGS Checklist. (Shiffman et al., 2003
). These items are:
- ‘Overview material’, which provides ‘a structured abstract that includes the guidelines release date, status (original, revised, updated) and print or electronic sources’.
- ‘Focus’, which describes ‘the primary disease/condition and intervention/service/technology that the guideline addresses, indicate any alternative preventive, diagnostic or therapeutic interventions that were considered during development’.
- ‘Goal’, which describes ‘the goal that following the guideline is expected to achieve, including a rationale for development of a guideline on this topic.’
- ‘User/setting’, which describes ‘the intended users of the guidelines (e.g., provider types, patients) and the settings in which the guideline(is) intended to be used.’
- ‘Target population’, which describes ‘the patient population eligible for guideline recommendations and lists any exclusion criteria’.
- ‘Developer’, which identifies ‘the organization(s) responsible for guideline development and the names/credentials/potential conflicts of interest of iindividuals involved in the guideline's development’.
- ‘Funding source/sponsor’, which identifies ‘the funding source/sponsor and describe(s) its role in developing and/or reporting the guideline. Disclose conflict of interest.’
- ‘Evidence collection’, which describes ‘the methods used to search the scientific literature, including the range of dates and databases searched and criteria used to filter the retrieved evidence.’
- ‘Recommendation grading criteria’, which describes ‘the criteria used to rate the quality of evidence that supports the recommendations and the system for describing the strength of the recommendations. Recommendation strength communicates the importance of adherence to a recommendation and is based on both the quality of the evidence and the magnitude of anticipated benefits or harms’.
- ‘Method for synthesizing evidence’, which describes ‘how evidence was used to create recommendations e.g. evidence tables, meta-analysis, decision analysis.’
- ‘Prerelease review’, which describes ‘how the guideline developer reviewed and/or tested the guidelines prior to release.’
- ‘Update plan’, which states ‘whether or not there is a plan to update the guideline and if applicable, an expiration date for this version of the guideline’.
- ‘Definitions,’ which ‘define unfamiliar terms and those critical to correct application of the guideline that might be subject to misinterpretation’.
- ‘Recommendations and rationale’, that ‘state the recommended action precisely and the specific circumstances under which to perform it. Justify each recommendation by describing the linkage between the recommendation and its supporting evidence. Indicate the quality of evidence and the recommendation strength, based on the criteria described in 9’.
- ‘Potential benefits and harm’, which ‘describe anticipated benefits and potential risks associated with implementation of guideline recommendations.’
- ‘Patient preferences’, which describes ‘the role of patient preferences when a recommendation involves a substantial element of personal choice or values’.
- ‘Algorithm’, which provides ‘(when appropriate) a graphic description of the stages and decisions in clinical care described by the guideline.’
- ‘ Implementation considerations’, which ‘describe anticipated barriers to application of the recommendations. Provide reference to any auxiliary documents for providers or patients that are intended to facilitate implementation. Suggest review criteria for measuring changes in care when the guideline is implemented’(Shiffman et al., 2003).
A careful look at the items reveals the comprehensive nature of this Checklist. Each item needs more than cursory perusal by those interested in salvaging CPGs from ulterior influence. Please do not just skim through them. Read and discuss how each item is important, so they register and maybe you may add a few to them yourself.
It includes items for standardization (Items 5,6,8,9,10), conceptual issues (Items 2,3,13,14), up gradation (Items 1,12,18), conflict of interest (Items 6,7), patient interest (Items 4,5,11,15,16,18) and systematization (Items 4,8,9,10,13,14,17,18). Even items for individual preferences, choice or values are not neglected (Item 16). Special mention must be made of Items 6 and 7, which specify disclosure of conflict of interest both in the Developer (including the organization that develops and the individuals involved in the guideline's formulation), as well as in the sponsor or funding source (and its role in developing and/or reporting the guideline). All salutary moves.
Another significant contribution of this checklist is its prospective use:
In contrast to other instruments that have been developed for post hoc evaluation of guideline quality, the COGS checklist is intended to be used prospectively by developers to improve their product by improving documentation (Shiffman et al., 2003
Also, it is the result of a consensus standard for prospective development of quality CPGs:
Although many individual organizations have devised manuals and procedures for developing guidelines, we are unaware of any consensus standard that has been proposed for use prospectively to promote the development of high-quality guidelines (Shiffman et al., 2003
The paper rightly ends with a call to overcome roadblocks in CPG use by carrying on a ‘sustained’ and ‘productive’ discussion amongst all the parties involved: developers, disseminators, implementers and ‘knowledge managers’ of guidelines:
A sustained and productive discussion among guideline developers, disseminators, implementers and knowledge managers about critical guideline items and clear statement of decidable and executable recommendations will help to overcome major impediments to guideline use (Shiffman et al., 2003
COGC is an important initiative in the right direction. Those interested in salvaging CPGs from market forces camouflaging as evidence-based medicine may neglect it at their own peril.