Clinical guidelines: read the scope, evidence and recommendation together
Clinical guidelines organise evidence into recommendations intended to support care. Their usefulness depends on applying the right document to the right question and understanding its limits. A recommendation should be read with its scope and reasoning, rather than as a sentence detached from the context in which it was developed.
Check who and what the document covers
Each guideline has a description of the populations, clinical questions and topics that are included or excluded. A clinical guideline for a single medical condition or patient population does not provide answers for similar but unrelated medical conditions or patient populations. In addition to determining if the clinical guideline applies to your patient, you need to check the version date and updates made to the guideline. When you copy a recommendation from a guideline into your progress notes, the version date, and updates can be lost. Therefore, knowing whether or not the recommendation still applies becomes difficult.
When revising, read a fictional recommendation and list the population, intervention and outcomes that it addresses. Next, identify a situation that would fall outside of the scope of this recommendation. This will help prevent a generic title from becoming a basis for believing that all problems related to that generic title are addressed. Determining the applicability of a clinical guideline should occur prior to assessing how much reliance you place upon the recommendation.
Recommendations are developed from more than a single study headline
While developing guidelines, evidence search methods are utilized to locate available evidence. Additionally, each identified piece of evidence is appraised using various techniques. Committees consisting of individuals with expertise in the area and representatives from consumer groups also evaluate each piece of evidence. The level of evidence and the potential benefits and harms associated with each option are used to develop clinical guidelines. The process of developing a clinical guideline involves synthesizing the rationales for each recommendation to assist clinicians with translating evidence-based medicine into practice.
Compare a research result with a recommendation derived from a broader evidence synthesis. Ask yourself what other factors could account for a difference between these two results. A finding may have low certainty, apply only to a small subset of patients, or have little relevance to desired outcomes. The useful skill is to track a claim back to its rationale for supporting that claim, rather than assume that all published findings deserve equal weighting.
The language can communicate different levels of certainty
Some organizations developing clinical guidelines use particular terms to indicate differing levels of certainty associated with a recommendation. For example, NICE uses terms like "offer" and "consider" depending on the strength and balance of evidence. Instead of assuming that all documents utilize consistent terminology or convey identical levels of certainty about recommendations, you should review the organization's explanation.
In a teaching comparison, retain the wording unchanged while providing an explanation regarding what that wording indicates within that document. Avoid strengthening cautionary recommendations when paraphrasing. Identify the degree of uncertainty and any conditions attached. Providing a faithful translation permits readers to distinguish between an option requiring consideration versus an option that is supported by more confidence.
Evidence needs to be discussed in the individual context
Clinical guidelines are used in conjunction with an individual's clinical status, preferences and professional obligations. Multiple conditions or treatment burdens can limit application of separate recommendations. Discussions must clearly articulate benefits, harms and options and allow decision-making. A guideline title alone cannot establish an individual's treatment nor substitute for a proper clinical evaluation.
To revise, explain how one recommendation relates to an individual's goals in a hypothetical scenario and identify what additional information is required. Record both the rationalization for using the recommendation along with plans for future reviews; do not merely record the title of the document. This webpage discusses how to read clinical guidelines; it does not replicate existing prescribing protocols or address which recommendations should guide an individual case.
Check your understanding
A short quiz, with an explanation after each answer.
What should be checked before applying a guideline?
Go back to the section you found most difficult and describe its example without reviewing this webpage. Review your description and retake the quiz again. Describing the rationale is a more valuable tool than remembering where a correct answer was located.