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Point and Counterpoint |

Rebuttal From Drs Nathanson and OuelletteRebuttal From Drs Nathanson and Ouellette 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.

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):16-17. doi:10.1378/chest.14-2234
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Dr Mehta and colleagues1 assert that optimal guidelines have four key characteristics: globalizing evidence; identifying ways to help consumers implement guidelines; focusing on important questions for patients and clinicians; and ensuring adaption, applicability, and transferability of guidelines.2 These are just the first four of 10 “key visions” listed in a 2012 workshop sponsored by the American Thoracic Society/European Respiratory Society that was an effort to standardize COPD evidence-based guidelines (EBGs).2 This represents a derivation of earlier collaborative work by the Institutes of Medicine (IOM) and the Agency for Health Research and Quality (AHRQ), wherein eight “Standards for Developing Trustworthy Guidelines” were developed.3 We stipulate that American College of Chest Physicians (now branded as CHEST) EBGs are developed with close attention to IOM and AHRQ recommendations and reaffirm that CHEST EBGs are global.

Nevertheless, they contend that CHEST EBGs are not “globally inclusive and relevant” because they do not offer recommendations for both first-world settings and third-world settings.1 We find these statements puzzling for several reasons.

CHEST EBGs address important conditions affecting patients and clinicians worldwide, and recent EBGs made recommendations about VTE and anticoagulation, lung cancer, pulmonary hypertension, cough, and mass casualty care.4-8 The process to create them followed international standards, used experts from all corners of the globe, and considered patient preferences.

So where do CHEST EBGs fall short? Dr Mehta and colleagues1 write that truly global EBGs must make recommendations for both first-world settings and “resource-poor settings, even if the latter are based only on expert opinion of knowledgeable health-care providers.” EBGs require graded actionable recommendations based on the best available evidence. Ignoring such evidence in favor of expert opinion because of resource considerations would create documents that do not meet standards set by IOM/AHRQ for trustworthy guidelines and would perpetuate rather than diminish health-care disparities.

The authors report that they want to lessen global health-care disparities and to provide a universally acceptable standard of care.1 They add that CHEST EBGs may not apply to residents of resource-poor regions. We believe that CHEST EBGs, by assessing the best available scientific evidence, provide standards of care that are of interest globally. Setting uniform recommendations for medical care is the best way to begin to reduce disparities, whereas providing markedly different recommendations that may not be evidence based for different regions of the world will accentuate them. We acknowledge that there are regional variations in medical practice based upon resource constraints and cultural and sociological differences. The best way for these challenges to be met is through EBG adaptation.

CHEST EBGs do not cover implementation of recommendations for every conceivable clinical situation around the globe, nor are representatives from every region of the world included on all of our panels. We rely on thoughtful clinicians everywhere to review our efforts and modify them to their situations. CHEST will help with this process. Worldwide collaboration is the key to reducing health-care disparities and improving the lives of patients, and collaboration is the hallmark of global CHEST EBGs.

References

Mehta AC, Banga A, Stoller JK. Counterpoint: are the CHEST guidelines global in coverage? No. Chest. 2015;147(1):13-15.
 
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]
 
IOM (Institute of Medicine). Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press; 2011. [PubMed] [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]
 
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]
 
Taichman DB, Ornelas J, Chung L, et al. Pharmacologic therapy for pulmonary arterial hypertension in adults: CHEST guideline and expert panel report. Chest. 2014;146(2):449-475. [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]
 
Christian MD, Devereaux AV, Dichter JR, Rubinson L, Kissoon N; on behalf of the Task Force for Mass Critical Care. Introduction and executive summary: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4_suppl):8S-34S. [CrossRef] [PubMed]
 

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References

Mehta AC, Banga A, Stoller JK. Counterpoint: are the CHEST guidelines global in coverage? No. Chest. 2015;147(1):13-15.
 
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]
 
IOM (Institute of Medicine). Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press; 2011. [PubMed] [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]
 
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]
 
Taichman DB, Ornelas J, Chung L, et al. Pharmacologic therapy for pulmonary arterial hypertension in adults: CHEST guideline and expert panel report. Chest. 2014;146(2):449-475. [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]
 
Christian MD, Devereaux AV, Dichter JR, Rubinson L, Kissoon N; on behalf of the Task Force for Mass Critical Care. Introduction and executive summary: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4_suppl):8S-34S. [CrossRef] [PubMed]
 
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