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Point and Counterpoint |

POINT: Are the CHEST Guidelines Global in Coverage? YesCHEST Guidelines Are Global FREE TO VIEW

Ian Nathanson, MD, FCCP; Daniel R. Ouellette, MD, FCCP
Author and Funding Information

Dr Nathanson is the Section Editor for Guidelines and Consensus Statements for CHEST. From the Department of Pulmonary and Critical Care Medicine, Henry Ford Health Care System (Dr Ouellette).

CORRESPONDENCE TO: Ian Nathanson, MD, FCCP, 838 Lake Catherine Ct, Maitland, FL 32751; e-mail: inathanson@cfl.rr.com


FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST the following conflicts of interest: Dr Nathanson is a former Chair of the Guidelines Oversight Committee. Dr Ouellette is the current Chair of the Guidelines Oversight Committee. He received a research grant from Cardeas Pharma (Principal Investigator, all funds to institution) and has been an expert witness on the topic of venous thromboembolism.

Reprodution of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;147(1):11-13. doi:10.1378/chest.14-2233
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Published online

The mission of the American College of Chest Physicians (now branded as CHEST) is “to champion the prevention, diagnosis, and treatment of chest diseases through education, communication and research.” To achieve this, the Board of Regents outlined five goals in the Strategic Plan for 2013 to 2017, with goal two calling for “a wide array of new relevant and useful guidelines, standards, and complementary programs that continue to guide the profession especially during value based health-care reform.”1 We contend that CHEST evidence-based guidelines (EBGs), long recognized for high quality,2 are global because they focus on topics of global importance, use processes accepted by multinational societies, and include panels of international experts. In addition, support and assistance from CHEST helps countries around the world adapt CHEST EBGs to enhance the ability of local practitioners to implement them.

CHEST EBGs inform practitioners around the globe about problems of universal scope. Clinical EBGs have concerned topics such as cough,3 lung cancer,4 and antithrombotics and anticoagulants.5 The first two EBGs focus on the most common symptom reported worldwide6 and the most common cause of cancer death worldwide.7 Heparin and warfarin, anticoagulant drugs, featured prominently in the CHEST EBG concerning antithrombotics and anticoagulants, are listed in the World Health Organization (WHO) List of Essential Medicines.8 This list provides guidance and support for economically challenged developing nations to devise national strategies aimed at providing these pharmaceuticals. In the United Nations International Covenant on Economic, Social, and Cultural Rights (ratified by 157 countries, May 2000), Article 12.2.d states that for individuals the “Right to health facilities, goods and services includes appropriate treatment of prevalent diseases, preferably at community level; and the provision of essential drugs as defined by the WHO Action Programme on Essential Drugs.”9 CHEST EBGs, therefore, inform practitioners about crucial and relevant topics, irrespective of the part of the world in which their practice is located.

CHEST produces EBGs using a rigorous process similar to that outlined by other organizations throughout the world.10-14 The Guidelines Oversight Committee (GOC) selects guideline topics and recruits content experts and methodologists. All potential panelists undergo review for conflicts of interest, with the majority having no significant financial or intellectual conflicts. However, GOC may restrict an individual’s participation or even disqualify a candidate panelist because of conflicts deemed to be unacceptable. Once formed, the guideline panel considers what important clinical issues it should address and subsequently creates PICO (population, intervention, comparator, outcome) questions that serve as the basis for extensive literature searches needed to establish evidence tables. After assessing and debating the strength of the evidence and considering patient preferences, panelists write and grade the final recommendations. The GOC then reviews the document before forwarding it to the Board of Regents, where it is again reviewed to determine if it is acceptable to become an official EBG of CHEST. The final review before publication is conducted by the CHEST journal.

In addition to using guideline development processes consistent with international standards, guideline panels consist of experts from around the globe. As an example, Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (AT9), one of the most prominent CHEST EBGs, was developed by a panel consisting of 123 expert members,5 the majority of whom (65 members, 52.8%) resided outside of the United States. One-fourth of the members were from countries outside of North America (30, 24.4%). The WHO’s Handbook for Guideline Development points out that EBGs should take into account how recommendations will be implemented at the local level.10 All CHEST EBGs include panelists who regularly care for patients in their local communities, and these panelists offer keen perspectives about the application of recommendations at the point of care. Using panels of international experts assures that CHEST EBGs address concerns of clinicians throughout the world, further reinforcing the global nature of CHEST EBGs.

The foundation of EBGs rests on the principles of evidence-based medicine, which integrate individual clinical expertise with the best available external information provided by systematic research.15 All CHEST EBGs are designed to inform medical practitioners of the evidence-based state of knowledge developed from careful analysis of the most recent topical research. Today, medical information is available via the Internet to practitioners around the globe. Internet access is one measure of the global reach of CHEST EBGs. Since 2012, Internet access to AT95 has generated 1,178,368 HTML or PDF downloads. Since its publication in 2013, the CHEST lung cancer guideline4 has generated 194,419 downloads. The CHEST journal website has > 3 million visitors and web sessions annually, with 58% of this traffic coming from outside of the United States (Steve Welch, BA, Senior Vice President and Publisher, CHEST, personal communication, July 30, 2014). Medical practitioners worldwide access the CHEST website (Table 1). Because CHEST EBGs are available on an Internet platform and accessible to any practitioner with Internet access, CHEST EBGs extend to all corners of the world. Access and use data demonstrate extensive worldwide access of CHEST EBGs, suggesting that they are global.

Table Graphic Jump Location
TABLE 1 ]  International Internet Access to CHEST by Country

Adaptation of guidelines refers to the process of modifying a guideline developed in one region of the world to the economic and cultural exigencies that exist in another. Validated tools exist that allow experts in evidence-based medicine to adapt existing guidelines to the needs of a specific country or region of the world.16 Guidelines are usually adapted by local and regional country experts who adapt relevant guidelines that have been created elsewhere. CHEST EBGs are global because they have been adapted and modified by experts in countries around the world, and CHEST has policies and procedures to facilitate and promote adaptation of all CHEST EBGs. Experts in Australia and New Zealand adapted the CHEST Antithrombotic and Anticoagulant seventh edition guideline to produce an evidence-based statement for practitioners in those countries.17 The Korean Society for Thrombosis and Hemostasis adapted the eighth edition of the CHEST antithrombotic and anticoagulant guideline to their country’s needs.18 The Norwegian Ministry of Health has adapted and updated the most recent version of the CHEST EBG for antithrombotics and anticoagulants (AT9) to the needs of their nation’s providers.19 Because of the widespread interest in adapting CHEST guidelines globally, the GOC of CHEST is in the process of developing policies and procedures to guide and support those interested in evidence-based medicine around the world to adapt CHEST EBGs to their particular circumstances.

CHEST guidelines are global. The breadth of topics covered by CHEST guidelines implicates important universal topics in medicine. CHEST EBGs are developed using broadly accepted processes and use international panels of experts. CHEST EBGs are widely accessed by practitioners from around the world. CHEST EBGs are being adapted to meet local and regional needs. CHEST fosters an atmosphere of collaboration and is providing guidance for worldwide use of CHEST guidelines.

Abbreviations

AHRQ

Agency for Health Research and Quality

AT9

Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

CHEST

American College of Chest Physicians

EBG

evidence-based guideline

EBUS

endobronchial ultrasound

GOC

Guidelines Oversight Committee

IOM

Institutes of Medicine

WHO

World Health Organization

Strategic plan. American College of Chest Physicians website. http://www.chestnet.org/About/Overview/Strategic-Plan. Accessed June 30, 2014.
 
Baumann MH, Lewis SZ, Gutterman D. ACCP evidence-based guideline development: a successful and transparent approach addressing conflict of interest, funding, and patient-centered recommendations. Chest. 2007;132(3):1015-1024. [CrossRef] [PubMed]
 
Irwin RS, Baumann MH, Bolser DC, et al; American College of Chest Physicians (ACCP). Diagnosis and management of cough executive summary: ACCP evidence-based clinical practice guidelines. Chest. 2006;129(1_suppl):1S-23S. [CrossRef] [PubMed]
 
Detterbeck FC, Lewis SZ, Diekemper R, Addrizzo-Harris D, Alberts WM. Executive summary: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5_suppl):7S-37S. [CrossRef] [PubMed]
 
Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ; for the American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive summary: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2_suppl):7S-47S. [CrossRef] [PubMed]
 
Madison JM, Irwin RS. Cough: a worldwide problem. Otolaryngol Clin North Am. 2010;43(1):1-13. [CrossRef] [PubMed]
 
Cancer. Fact sheet No. 297. World Health Organization website. http://www.who.int/mediacentre/factsheets/fs297/en/. Updated February 2014. Accessed July 14, 2014.
 
WHO model list of essential medicines. World Health Organization website. http://apps.who.int/iris/bitstream/10665/93142/1/EML_18_eng.pdf. Published April 2013. Accessed July 14, 2014.
 
The United Nations Committee on Economic, Social, and Cultural Rights. The right to the highest attainable standard of health. 11/08/2000. E/.12/2000/4, CESCR General Comment 14, para 12(a).
 
WHO handbook for guideline development. World Health Organization website. http://apps.who.int/iris/bitstream/10665/75146/1/9789241548441_eng.pdf. Accessed June 30, 2014.
 
Standards for developing trustworthy clinical practice guidelines. Institute of Medicine website. http://www.iom.edu/Reports/2011/Clinical-Practice-guidelines-We-Can-Trust/Standards.aspx. Published 2011. Accessed June 30, 2014.
 
Qaseem A, Forland F, Macbeth F, Ollenschläger G, Phillips S, van der Wees P; Board of Trustees of the Guidelines International Network. Guidelines International Network: toward international standards for clinical practice guidelines. Ann Intern Med. 2012;156(7):525-531. [CrossRef] [PubMed]
 
The National Institute for Health and Clinical Excellence. NICE Clinical Guidelines: The Guidelines Manual. London, England; 2009.
 
Scottish Intercollegiate Guidelines Network. SIGN 50: A Guideline Developer’sH. Edinburgh, Scotland: Scottish Intercollegiate Guidelines Network; 2008.
 
Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ. 1996;312(7023):71-72. [CrossRef] [PubMed]
 
The Adapte Collaboration. Adapte resource toolkit for guideline adaptation. Version1.0. Guidelines International Network website. http://www.g-i-n.net. Published 2007. Accessed June 30, 2014.
 
The Australian and New Zealand Working Party on the Management and Prevention of Venous Thromboembolism. Prevention of Venous Thromboembolism: Best Practice Guidelines for Australia and New Zealand.4th ed. Sydney, Australia: Health Education and Management International; 2007.
 
Bang S-M, Jang MJ, Kim KH, et al. Prevention of venous thromboembolism, 2nd edition: Korean Society of Thrombosis and hemostasis evidence-based clinical practice guidelines. J Korean Med Sci. 2014;29(2):164-171. [CrossRef] [PubMed]
 
Kristiansen A, Brandt L, Agoritsas T, et al. Applying new strategies for the national adaptation, updating, and dissemination of trustworthy guidelines: results from the Norwegian adaptation of the antithrombotic therapy and the prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2014;146(3):735-761. [CrossRef] [PubMed]
 

Figures

Tables

Table Graphic Jump Location
TABLE 1 ]  International Internet Access to CHEST by Country

References

Strategic plan. American College of Chest Physicians website. http://www.chestnet.org/About/Overview/Strategic-Plan. Accessed June 30, 2014.
 
Baumann MH, Lewis SZ, Gutterman D. ACCP evidence-based guideline development: a successful and transparent approach addressing conflict of interest, funding, and patient-centered recommendations. Chest. 2007;132(3):1015-1024. [CrossRef] [PubMed]
 
Irwin RS, Baumann MH, Bolser DC, et al; American College of Chest Physicians (ACCP). Diagnosis and management of cough executive summary: ACCP evidence-based clinical practice guidelines. Chest. 2006;129(1_suppl):1S-23S. [CrossRef] [PubMed]
 
Detterbeck FC, Lewis SZ, Diekemper R, Addrizzo-Harris D, Alberts WM. Executive summary: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5_suppl):7S-37S. [CrossRef] [PubMed]
 
Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ; for the American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive summary: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2_suppl):7S-47S. [CrossRef] [PubMed]
 
Madison JM, Irwin RS. Cough: a worldwide problem. Otolaryngol Clin North Am. 2010;43(1):1-13. [CrossRef] [PubMed]
 
Cancer. Fact sheet No. 297. World Health Organization website. http://www.who.int/mediacentre/factsheets/fs297/en/. Updated February 2014. Accessed July 14, 2014.
 
WHO model list of essential medicines. World Health Organization website. http://apps.who.int/iris/bitstream/10665/93142/1/EML_18_eng.pdf. Published April 2013. Accessed July 14, 2014.
 
The United Nations Committee on Economic, Social, and Cultural Rights. The right to the highest attainable standard of health. 11/08/2000. E/.12/2000/4, CESCR General Comment 14, para 12(a).
 
WHO handbook for guideline development. World Health Organization website. http://apps.who.int/iris/bitstream/10665/75146/1/9789241548441_eng.pdf. Accessed June 30, 2014.
 
Standards for developing trustworthy clinical practice guidelines. Institute of Medicine website. http://www.iom.edu/Reports/2011/Clinical-Practice-guidelines-We-Can-Trust/Standards.aspx. Published 2011. Accessed June 30, 2014.
 
Qaseem A, Forland F, Macbeth F, Ollenschläger G, Phillips S, van der Wees P; Board of Trustees of the Guidelines International Network. Guidelines International Network: toward international standards for clinical practice guidelines. Ann Intern Med. 2012;156(7):525-531. [CrossRef] [PubMed]
 
The National Institute for Health and Clinical Excellence. NICE Clinical Guidelines: The Guidelines Manual. London, England; 2009.
 
Scottish Intercollegiate Guidelines Network. SIGN 50: A Guideline Developer’sH. Edinburgh, Scotland: Scottish Intercollegiate Guidelines Network; 2008.
 
Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ. 1996;312(7023):71-72. [CrossRef] [PubMed]
 
The Adapte Collaboration. Adapte resource toolkit for guideline adaptation. Version1.0. Guidelines International Network website. http://www.g-i-n.net. Published 2007. Accessed June 30, 2014.
 
The Australian and New Zealand Working Party on the Management and Prevention of Venous Thromboembolism. Prevention of Venous Thromboembolism: Best Practice Guidelines for Australia and New Zealand.4th ed. Sydney, Australia: Health Education and Management International; 2007.
 
Bang S-M, Jang MJ, Kim KH, et al. Prevention of venous thromboembolism, 2nd edition: Korean Society of Thrombosis and hemostasis evidence-based clinical practice guidelines. J Korean Med Sci. 2014;29(2):164-171. [CrossRef] [PubMed]
 
Kristiansen A, Brandt L, Agoritsas T, et al. Applying new strategies for the national adaptation, updating, and dissemination of trustworthy guidelines: results from the Norwegian adaptation of the antithrombotic therapy and the prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2014;146(3):735-761. [CrossRef] [PubMed]
 
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