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The Clinical Practice Guidelines are recommendations for physicians regarding the care of patients with specific conditions. They should be based on the best available research evidence and practical experience. The guidelines are suggestions for care, not rules. There will always be individual patients who should be treated differently.
It is convenient to analyze some differences within what is generically called guides. The international medical community frequently uses the PubMed search engine (PubMed.gov) to perform queries on sci entific content in the health sciences. On this site, it is also possible to find guides and/or consensus. On its home page, the search terms are written, and the search will be completed after pressing the Search button. As a result, a series of bibliographic references will be obtained. Then, it is possible to narrow down the search to selected items, such as Article type. Within this category, up to six different options may be selected. Additional filters can also be applied to further narrow down the search1.
As anticipated in the title, we are interested in the item Consensus. In this regard, it is possible to find similar terms: Consensus Development Conference, Guideline, Practice Guidelines. The National Library of Medicine (NIH, https://www.ncbi.nlm.nih.gov/) defines Guideline as:
• A set of statements, instructions, or principles that determines current or future rules or policies.
• The text can be discursive or schematic, but is generally a comprehensive guide to problems and approaches in any discipline or activity.
• This concept relates to the management and administration of health care activities rather than deci sions specific to a particular clinical condition. To that end, the Practice Guidelines are available.
What are clinical practice guides, recommendations and consensus?
On the other hand, the NHI distinguishes Practice Guideline, as well as its equivalents Clinical Prac tice Guidelines, Treatment Guidelines, Clinical Guidelines) as:
• Work that consists of a set of instructions or principles to assist the health professional to make deci sions on patient care, diagnostic, therapeutic, or other appropriate clinical procedures for specific clinical circumstances.
• They can provide a basis for evaluating the quality and effectiveness of health care in measuring health improvement, reducing variation in services or procedures performed, and reducing variation in health care outcomes.
In both cases, the guidelines may be developed by government agencies, institutions, and organiza tions, such as professional societies or boards of directors, or by convening expert panels. The differ ence between Guidelines and Practice Guidelines (or their equivalents) is, that the former are current or future general rules or policies, while the latter is more specific for making decisions about patient care in specific clinical circumstances. This may seem irrelevant, however, “guides” are usually heterogeneous, and frequently more suited to topic summaries with variable degrees of schematization and even recom mendations.
On its website2, the Ministry of Health of Argentina defines Clinical Practice Guide (CPG) as a set of recommendations developed in a systematic way to guide professionals and patients in making decisions
about the most appropriate health care for the different screening, diagnosis and/or treatment options for a specific health problem or condition. The content of the CPG is developed according to methodologies of systematic search, critical appraisal, analysis and synthesis of the best available evidence. The CPGs should be designed to support the decision-making decision-making process in patient care, in conjunc tion with the clinical criteria of the treating professional, and the values and preferences of the person”.
A consensus, according to the Dictionary of the Royal Spanish Academy3, is “an agreement produced by consent between all the members of a group or between several groups”. From the point of view of medical practice, it should respect the same methodology as that referred to for a CPG. In other words, recommendations, CPG and consensus should be critically evaluated in the same way.
Why do clinical practice guide appear in the medical literature?
Recommendations for clinical management of a patient are currently being developed in the face of an ever-growing flood of information. Medical committees have developed clinical practice guidelines4 that include recommendations aimed at optimizing patient care. Ideally, they are based on a systematic review of the evidence and assessing the benefits and harms of alternative care options5.
To make a recommendation, guideline panelists should define clinical questions, select the variables and outcomes, retrieve and synthesize all relevant evidence, rate the confidence in effect estimates, and, based on a systematic approach but also in the consensus between the intervening parties, translate the recommendations. Guides should provide recommendations and the key information on which the recommendations are based6.
Are the clinical practice guide sufficient for clinical practice?
GPC readers must understand that evidence is never sufficient to guide clinical practice: patient val ues and preferences are always crucial. Many, probably most, of the important clinical decisions depend on the values and preferences of the patients: the right choice for one individual may be the wrong choice for another.
Furthermore, guidelines on the same clinical question developed by different expert groups often provide different recommendations; although the differences are generally minor and, very rarely, the recommendations are very different.
The application of guidelines developed to address a specific condition in patients with multiple comor bidities is a field with many inaccuracies. Therefore, shared decision-making is essential for evidence-based practice. To participate in shared decision-making, clinicians must understand the magnitude of benefits, harms, and burdens associated with clinical management alternatives, along with the certainty of the evidence, and also be able to discuss them with patients7.
When to trust a clinical practice guide?
Reliable recommendations should specify strength and a rating of confidence in the effect estimates that support them (also known as certainty of the evidence)8.
There are dozens of rating systems for recommendations. The three most commonly used approach es are Grading of Recommendations Assessment, Development and Evaluation (GRADE)9 and those used by the American Heart Association (AHA)10 and the US Preventive Task Force (USPSTF)11.
Table 1 describes direction (for or against) and strength (strong or weak) of the recommendations suggested by the three indicated systems and their equivalences12.
In the User Guides12 to evaluate the recommendations, a series of conditions are established to con sider reliable CPGs, which are summarized in the following questions and which should be used for the critical analysis of recommendations, consensus, and CPG:
1. Is the clinical question clear and complete?
• Is the recommended intervention clear and feasible?
• Is the alternative clear?
• Were all patient-relevant outcomes explicitly considered?
2. Was the recommendation based on the best current evidence?
3. Are the values and preferences associated with the results adequately specified?
4. Do the authors indicate the strength of their recommendations?
5. Is the evidence supporting the recommendation easily understood?
6. For strong recommendations, is appreciation adequate?
7. In the case of weak recommendations, does the information provided facilitate shared decision-making?
8. Was the influence of the conflict of interest minimized?
Of the evaluation tools named, a national experience offering a question answering service based on the GRADE approach has been efficient and feasible to use recommendations based on the best evidence13.
What is the quality of the clinical practice guide that are currently published?
A considerable proportion of the published guides have methodological problems and are unreliable. The directors of the panels that prepare the guides have conflicts of interest or have a format that makes them difficult to apply in daily practice. In general, they do not consider the preferences of the patients when making the recommendations14,15. It has been found that World Health Organization guidelines of ten make strong recommendations based on low confidence estimates16. In certain situations, this could be justified. For example, when an intervention based on evidence of poor quality prove beneficial while another high quality has high cost (and therefore difficult to implement in low-income areas) or presents associated risks.
What is the main aim of this new section?
There may be significant gaps between CPGs and the clinical practice itself. Paraphrasing the “Guide for the Adaptation of Clinical Practice Guidelines”, this section aims to contribute to increasing the qual ity of the published recommendations, consensus, and CPGs, stimulating the adjustment (fast or with updating) of those produced nationally and internationally17.
