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Point and Counterpoint |

COUNTERPOINT: Are the CHEST Guidelines Global in Coverage? NoCHEST Guidelines Are Not Global FREE TO VIEW

Atul C. Mehta, MD, FCCP; Amit Banga, MD, FCCP; James K. Stoller, MD, FCCP
Author and Funding Information

From the Respiratory Institute (Drs Mehta, Banga, and Stoller) and the Education Institute (Dr Stoller), Cleveland Clinic.

CORRESPONDENCE TO: Atul C. Mehta, MD, FCCP, Respiratory Institute, Cleveland Clinic, 9500 Euclid Ave, A-90, Cleveland, OH 44195; e-mail: Mehtaa1@ccf.org


FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

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


Chest. 2015;147(1):13-15. doi:10.1378/chest.14-2235
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Published online

Clinical practice guidelines have proliferated in the last decade, with > 3,700 guidelines reported in the Guidelines International Network database.1 In chest medicine alone, > 150 current guidelines are posted on the websites of official international societies, including the American College of Chest Physicians (now branded as CHEST).2 A central goal in developing guidelines is to provide evidence-based recommendations to optimize care for as many patients as possible. In this context, guidelines should be broadly applicable to impact the care of the most patients possible. Indeed, as stated in CHEST’s Evidence-Based Medicine Overview,3 “our guidelines are used throughout the world” and “have received considerable acclaim and worldwide use.” Also articulating these goals and in keeping with early recommendations,4 the American Thoracic Society Guide to Guidelines for Professional Societies states that guidelines should incorporate “consideration of cost-effectiveness, affordability, and resource implications” and “stakeholder involvement: how to do it right.”5 Key characteristics of an optimal guideline were considered the ability to (1) “globalize the evidence,” (2) “identify ways that help guideline consumers understand and implement guidelines,” (3) “focus on questions that are important to patients and clinicians,” and (4) ensure “adaptation, applicability, and transferability of guidelines.”5

Substantial evidence supports the overall benefits of guidelines.6,7 Even in the face of incomplete adoption of some evidence-based practices,8,9 guidelines have been shown to favorably affect patient outcomes, help summarize large bodies of the literature for busy clinicians, and ideally discourage use of unsupported practices.6,7 Notwithstanding these substantial successes, it is reasonable to ask whether available guidelines developed by global organizations like CHEST have realized the stated goal of “globalizing the evidence” and “worldwide use.” Stated simply, are global guidelines globally inclusive and relevant? We think not.

Addressing this question requires considering the global diversity of health care and the full range of patient populations affected by the medical conditions that guidelines address. To be globally inclusive and relevant, the recommendations in guidelines must be actionable. To be actionable, the recommended tests and therapies must be available in the target settings and populations. Said differently, recognizing that access to tests and therapies varies greatly within and between countries and that disparities in care exist, guidelines can only “globalize the evidence” if they offer recommendations that recognize global variation in access to tests and treatments.

Consider the cases of COPD and lung cancer. COPD is currently the fourth leading cause of mortality worldwide and projected to become the third most frequent cause of death by 2030.10 Globally, the greatest number of patients with COPD live in the most populous countries, such as China and India, where exposure to biomass fuels may exceed cigarette smoking as a risk factor by threefold.11 More importantly, deaths due to COPD are disproportionately represented among developing countries.12 Central aspects of all COPD guidelines13,14 include prevention by smoking cessation or avoidance; testing by spirometry, oximetry, and arterial blood gases; and treatment with various bronchodilators, inhaled corticosteroids, pulmonary rehabilitation, and supplemental oxygen as indicated. Yet, access to even these relatively simple interventions may be sparse in the very places where the disease burden is greatest globally.15 Access to more sophisticated interventions, such as lung volume reduction surgery or transplantation, is even more limited in resource-poor settings, of course. In this context, can it be said that COPD guidelines satisfy the goals of “globalizing the evidence” or having broad impact?

Lung cancer poses a similar paradox. Lung cancer is projected to be the sixth leading cause of death worldwide by 2030,10 and, in contrast to the developed world, the incidence in the developing world is increasing.16 Mainstays of lung cancer guideline recommendations, including those from CHEST,17 include preventive practices of smoking avoidance or cessation, testing with imaging modalities like CT and PET scans, diagnosis by tissue sampling (including bronchoscopy and advanced bronchoscopic techniques like endobronchial ultrasound [EBUS]), and treatment with surgery, radiation therapy, and an increasing array of drugs that mechanistically target growth factors.

Yet, as with COPD, access to these interventions may be limited in the developing world. As one measure of variation in access, the European Society for Medical Oncology reported that access to medical oncologists was much more limited in developing countries than elsewhere.18 For example, in India, the number of medical oncologists per million population was 0.98, as compared with > 50 oncologists per million population in several European countries.18 Access to diagnostic or therapeutic interventions likely mirrors this pattern. For example, a 2005 survey of pulmonologists in India regarding bronchoscopic practices indicated that none of the respondents reported use of EBUS in their clinical practice.19 In this context, can it be said that guidelines that recommend interventions like EBUS-aided bronchoscopy satisfy the goal of “globalizing the evidence”?

Taken together, despite the substantial benefit of guidelines in the developed (“first”) world, there is a disconnect between the global aspiration of guidelines and their capacity to impact under resourced patient populations in the “third” world. Given global health-care disparities, guidelines must both account for the context in which they will be implemented and address the full spectrum of settings in which the burden of disease occurs. For example, ideal COPD guidelines would offer recommendations for both resource-rich and resource-poor settings, recognizing that the evidence for resource-poor settings may be sparse and less robust.

The question might be asked: How relevant and inclusive are current guidelines? To address this question, we reviewed the major existing guidelines regarding COPD and lung cancer. Specifically, was there any explicit mention in the guideline of how the recommendations for diagnosis or treatment applied in resource-poor settings? In the case of the two major guidelines for lung cancer—those by CHEST17 and the American Society of Clinical Oncology20—neither addressed the specific challenges of preventing, diagnosing, or treating lung cancer in the developing world. Similarly, neither the COPD guidelines from the consortium of the American Thoracic Society, CHEST, and the European Respiratory Society14 nor those from GOLD (Global Initiative for Chronic Obstructive Lung Disease)13 offer specific recommendations regarding resource-poor settings.

We acknowledge that skeptics might regard this call to globalize guideline-based recommendations as silly. Obviously, to the extent that the weight of evidence comes from first-world settings, their applicability appropriately focuses on first-world populations. Still, the point remains that the burden of diseases that guidelines address is frequently greatest in resource-poor settings, where health-care providers labor to mitigate disease just like those who practice in resource-privileged settings. For guidelines to be truly globally relevant, they must include recommendations for both first-world settings (that are based on systematic review of the most rigorous evidence) and for resource-poor settings, even if the latter are based only on expert opinion of knowledgeable health-care providers.

Overall, truly globalizing clinical practice guidelines requires ensuring that guidelines address the full range of affected populations. Clearly, our greatest priority should be to lessen global health-care disparities and to provide a universally acceptable standard of care. So, do CHEST guidelines (or others) provide global coverage? We believe the answer is “no.” Until the goals of inclusiveness and global relevance are achieved, fulfilling the global aspiration of clinical practice guidelines requires that they offer recommendations for both first-world settings and third-world settings. For the latter, recommendations may be based on the expert consensus opinions of clinicians who care for these patients. Although critics may argue that the very reason that guidelines are developed is to avoid the shortcomings of expert opinion alone and to capture the rigor of robust research, we submit that failing to address resource-poor settings because research is not available overlooks the best available wisdom that context experts can provide. In the end, as we “globalize the evidence,” let us not make perfect the enemy of good.

References

IOM (Institute of Medicine). Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press; 2011. [PubMed] [PubMed]
 
Guidelines & resources. CHEST website. http://www.chestnet.org/Guidelines-and-Resources. Accessed April 21, 2014.
 
Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ. 1996;312(7023):71-72. [CrossRef] [PubMed]
 
Schünemann HJ, Woodhead M, Anzueto A, et al; ATS/ERS Ad Hoc Committee on Integrating and Coordinating Efforts in COPD Guideline Development. A guide to guidelines for professional societies and other developers of recommendations: introduction to integrating and coordinating efforts in COPD guideline development. An official ATS/ERS workshop report. Proc Am Thorac Soc. 2012;9(5):215-218. [CrossRef] [PubMed]
 
Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet. 1993;342(8883):1317-1322. [CrossRef] [PubMed]
 
Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. BMJ. 1999;318(7182):527-530. [CrossRef] [PubMed]
 
Esteban A, Ferguson ND, Meade MO, et al; VENTILA Group. Evolution of mechanical ventilation in response to clinical research. Am J Respir Crit Care Med. 2008;177(2):170-177. [CrossRef] [PubMed]
 
Kahn JM. Disseminating clinical trial results in critical care. Crit Care Med. 2009;37(suppl 1):S147-S153. [CrossRef] [PubMed]
 
Projections of mortality and causes of death, 2015 and 2030. World Health Organization website. http://www.who.int/healthinfo/global_burden_disease/projections/en. Accessed April 21, 2014.
 
Salvi SS, Barnes PJ. Chronic obstructive pulmonary disease in non-smokers. Lancet. 2009;374(9691):733-743. [CrossRef] [PubMed]
 
Mathers CD, Lopez AD, Murray CJ. The burden of disease and mortality by condition: data, methods, and results for 2001.. In:Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ., eds. Global Burden of Disease and Risk Factors. Washington, DC: The International Bank for Reconstruction and Development/The World Bank Group; 2006.
 
Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Global Initiative for Chronic Obstructive Lung Disease website. http://www.goldcopd.org/uploads/users/files/GOLD_Report_2011_Feb21.pdf. Accessed April 21, 2014.
 
Qaseem A, Wilt TJ, Weinberger SE, et al; American College of Physicians; American College of Chest Physicians; American Thoracic Society; European Respiratory Society. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. 2011;155(3):179-191. [CrossRef] [PubMed]
 
Srinath Reddy K, Shah B, Varghese C, Ramadoss A. Responding to the threat of chronic diseases in India. Lancet. 2005;366(9498):1744-1749. [CrossRef] [PubMed]
 
Lam WK, White NW, Chan-Yeung MM. Lung cancer epidemiology and risk factors in Asia and Africa. Int J Tuberc Lung Dis. 2004;8(9):1045-1057. [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]
 
Developing countries oncology survey (DC-OS) report 2006. European Society for Medical Oncology website. http://www.esmo.org/content/download/8399/170349/file/DC_Survey_Report_Istanbul.pdf. Accessed April 21, 2014.
 
Sandhya N. Bronchoscopy in India 2005: a survey. J Bronchol. 2006;13(4):194-200. [CrossRef]
 
Pisters KM, Evans WK, Azzoli CG, et al; Cancer Care Ontario; American Society of Clinical Oncology. Cancer Care Ontario and American Society of Clinical Oncology adjuvant chemotherapy and adjuvant radiation therapy for stages I-IIIA resectable non small-cell lung cancer guideline. J Clin Oncol. 2007;25(34):5506-5518. [CrossRef] [PubMed]
 

Figures

Tables

References

IOM (Institute of Medicine). Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press; 2011. [PubMed] [PubMed]
 
Guidelines & resources. CHEST website. http://www.chestnet.org/Guidelines-and-Resources. Accessed April 21, 2014.
 
Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ. 1996;312(7023):71-72. [CrossRef] [PubMed]
 
Schünemann HJ, Woodhead M, Anzueto A, et al; ATS/ERS Ad Hoc Committee on Integrating and Coordinating Efforts in COPD Guideline Development. A guide to guidelines for professional societies and other developers of recommendations: introduction to integrating and coordinating efforts in COPD guideline development. An official ATS/ERS workshop report. Proc Am Thorac Soc. 2012;9(5):215-218. [CrossRef] [PubMed]
 
Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet. 1993;342(8883):1317-1322. [CrossRef] [PubMed]
 
Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. BMJ. 1999;318(7182):527-530. [CrossRef] [PubMed]
 
Esteban A, Ferguson ND, Meade MO, et al; VENTILA Group. Evolution of mechanical ventilation in response to clinical research. Am J Respir Crit Care Med. 2008;177(2):170-177. [CrossRef] [PubMed]
 
Kahn JM. Disseminating clinical trial results in critical care. Crit Care Med. 2009;37(suppl 1):S147-S153. [CrossRef] [PubMed]
 
Projections of mortality and causes of death, 2015 and 2030. World Health Organization website. http://www.who.int/healthinfo/global_burden_disease/projections/en. Accessed April 21, 2014.
 
Salvi SS, Barnes PJ. Chronic obstructive pulmonary disease in non-smokers. Lancet. 2009;374(9691):733-743. [CrossRef] [PubMed]
 
Mathers CD, Lopez AD, Murray CJ. The burden of disease and mortality by condition: data, methods, and results for 2001.. In:Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ., eds. Global Burden of Disease and Risk Factors. Washington, DC: The International Bank for Reconstruction and Development/The World Bank Group; 2006.
 
Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Global Initiative for Chronic Obstructive Lung Disease website. http://www.goldcopd.org/uploads/users/files/GOLD_Report_2011_Feb21.pdf. Accessed April 21, 2014.
 
Qaseem A, Wilt TJ, Weinberger SE, et al; American College of Physicians; American College of Chest Physicians; American Thoracic Society; European Respiratory Society. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. 2011;155(3):179-191. [CrossRef] [PubMed]
 
Srinath Reddy K, Shah B, Varghese C, Ramadoss A. Responding to the threat of chronic diseases in India. Lancet. 2005;366(9498):1744-1749. [CrossRef] [PubMed]
 
Lam WK, White NW, Chan-Yeung MM. Lung cancer epidemiology and risk factors in Asia and Africa. Int J Tuberc Lung Dis. 2004;8(9):1045-1057. [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]
 
Developing countries oncology survey (DC-OS) report 2006. European Society for Medical Oncology website. http://www.esmo.org/content/download/8399/170349/file/DC_Survey_Report_Istanbul.pdf. Accessed April 21, 2014.
 
Sandhya N. Bronchoscopy in India 2005: a survey. J Bronchol. 2006;13(4):194-200. [CrossRef]
 
Pisters KM, Evans WK, Azzoli CG, et al; Cancer Care Ontario; American Society of Clinical Oncology. Cancer Care Ontario and American Society of Clinical Oncology adjuvant chemotherapy and adjuvant radiation therapy for stages I-IIIA resectable non small-cell lung cancer guideline. J Clin Oncol. 2007;25(34):5506-5518. [CrossRef] [PubMed]
 
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