Cardiology Magazine — May-June 2011
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Cover Story

There are several factors such as technology and the increased focus on relationships with industry (RWI) that are contributing to what many physicians are saying is a clear need for a more streamlined and effective way to navigate through the myriad available science and place important guidelines and other clinical documents directly in the hands of care providers, which will help patients with a broad range of clinical problems.

While the American College of Cardiology’s (ACC’s) evidence- based guidelines, expert consensus documents and appropriate use criteria are extensive and well documented, they are like textbooks – not easily portable and can’t be used quickly when approaching a specific patient. The information on a specific condition, while potentially available, is very difficult to collect. There has been much debate about changing the way the guidelines are created, and there are several solutions currently underway.

Cardiologists, who have led the way in developing clinical practice guidelines, are practicing during a time when there is increasedEmphasis on evidence-based medicine. For example, physicians see a patient with a specific set of clinical problems and are then asked to provide an opinion on the best and most current strategies of care. The clinician may not have read the most recent guideline related to this, which may be 100 pages long, or may not have seen the most recent information related to the specific problem. However, he or she is expected by the referring physician, the patient, the family and society to indeed render an expert opinion.

The Institute of Medicine (IOM) has spent the past year looking at guidelines and guideline developers and released a report in March with the standards for developing trustworthy clinical practice guidelines. Those include establishing transparency, managing RWI, creating multidisciplinary guideline development group composition, performing systematic evidence review, establishing evidence foundations for rating strength of recommendations, articulating recommendations, establishing external review and routinely updating the guidelines.It is noteworthy that the ACC/American Heart Association (AHA) clinical practice guidelines are nearly perfectly aligned with these recommended standards.

The ACC is working creatively to help meet the needs of all physicians in providing point-of-care information that is crucial for decision-making. The ACC is implementing a phased approach with many components. Each phase brings the guidelines to a more usable format for its members to put into practice at the point of care. The eventual goal will be to incorporate this point-of-care technology into all cardiovascular professional-patient care interactions, creating a portfolio of learning and quality of care opportunities.

Technology has undergone a series of revolutions that have had a dramatic impact on communication opportunities for cardiologists.Approximately 4-out-of-5 cardiologists (79 percent) use a mobile device in their work, according to a recent CardioSurve survey. Cardiologists primarily use their mobile devices to access reference material (61 percent) followed by point-of-care decision-making at 39 percent. So, the devices are having a powerful impact on real-time clinical decision-making. One-third (32 percent) of cardiologists use their mobile devices at least once a day to access clinical cardiology information, news or education. Physicians are also using the Internet for multiple reasons. While there is a universal need for the latest clinical guidelines (77 percent) and browsing by topics (58 percent), practitioners in private practice are more likely to go online for CME credit (76 percent), clinical searches (67 percent) and drug inforMation (44 percent); academic and hospital-based physicians are more focused on online textbooks/references (57 percent) and journal scans (57 percent).

“The ACCF/AHA Task Force on Practice Guidelines is trying to decrease the text and change the way the information is provided within practice guidelines by improving the process and enhancing Improvement workgroup was convened and reviewed the overall guideline process to consider strategies to increase timeliness, efficiency, relevance at the point of care, and fluidity of the process while maintaining the ACC and AHA quality and brand equity in the arena of evidence-based medicine for cardiovascular practitioners. New process improvements in writing guidelines include less text, links to evidence/summary tables, references and abstracts, and use of color coded charts. The methods by which evidence is obtained and evaluated are also being reviewed, and a scoring.

System for randomized clinical trials that was created is currently being tested for validity and reliability. Moreover, use of comparator verbs has been implemented for writing recommendations based on comparative effectiveness studies.

“We think it is important to maintain the ACC/AHA brand, but we are sensitive to the needs of practicing clinicians and are focused on the relevance and usefulness of guidelines at the point of care” said Jacobs.

Stricter rules with regard to RWI have also been discussed. The ACC and the AHA have long had strict policies for preventing any undue influence of industry within guidelines. Both organizations refined their policies in early 2010 to require even more stringent management of RWI, to align with the Council of Medical Specialty Societies (CMSS). The ACCF/AHA RWI Policy for Clinical Practice Guidelines includes the following:

• The chair of the guideline writing panel may not have any relevant RWI.

• In addition to the chair, a majority (at least 50 percent) of guideline writing committee members must not have any relevant RWI. • A writing committee member may not draft a recommendation or text or vote on any recommendation that is relevantto any of their industry relationships.

• Members of the final guideline approval bodies, the Board of Trustees of the ACC and the Science Advisory Coordinating Committee of the AHA, also must recuse themselves from voting if they have a relevant RWI.

The Task Force on Practice Guidelines is planning to hold a Guideline Methodology Summit in December to review the current methodology. Potential changes to the way evidence is obtained and evaluated and to the system used to generate recommendations will be considered. The Task Force will also determine how best to further align with the IOM recommendations for trustworthy guideline developers

Jacobs noted, “We’ve reviewed each phase of our process – writing, peer review, approval and publication, with the purpose of streamlining the work and shortening the timeline while maintaining the rigor and quality of the overall guideline development.We will now turn our attention to enhancing our methodology at the summit. Our overarching goal is to create a “living” document that allows for a timely, thorough and thoughtful review and assimilation of the continuous stream of new data, and that ultimately fosters the practice of evidence- based cardiology at the point of care.”