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Point and Counterpoint |

Rebuttal From Dr Mehta et alRebuttal From Dr Mehta et al 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):17-18. doi:10.1378/chest.14-2236
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We appreciate Drs Nathanson and Oulette’s1 response and concur that American College of Chest Physicians (now branded as CHEST) evidence-based guidelines (EBGs) are rigorously prepared and are of high quality. Notwithstanding their considerable value, CHEST EBGs still fail to achieve global coverage. To offer global coverage and relevance, EBGs must satisfy the condition of addressing clinical issues and circumstances of global patient populations (ie, patients throughout the range of socioeconomic circumstances and access to health-care technology and expertise). Our colleagues offer four lines of reasoning to defend their “pro” position; we believe that this rebuttal debunks each.

First, they argue that EBGs are global “because they focus on topics of global importance.”1 Although the statement is true, it hardly satisfies the criterion of global coverage. For example, lung cancer certainly affects patients all over the world, but using endobronchial ultrasound (EBUS) to stage lung cancer is available to only a tiny subset of those patients. Hence, a guideline that endorses EBUS without addressing what to do in populations where EBUS is unavailable lacks global coverage.

Their second argument is that development of EBGs uses “processes accepted by multinational societies” and that international societies have adopted them. Here again, we believe that the reasoning is true but fails to establish global coverage. For example, the issue is not whether the Korean Society of Thrombosis and Hemostasis has adopted the CHEST EBG on antithrombotics2 but whether the guideline itself addresses all the needs of Korean patients who may lack access to the latest therapeutic agents. Adoption of EBGs by international societies is not tantamount to global coverage and relevance. Furthermore, we are aware that some international societies have elected to prepare their own guidelines, reflecting a perceived unmet need.3,4

Their third argument is that EBGs have global coverage because they “include panels of international experts” in their preparation. Inclusion is, of course, a start toward global relevance but fails to achieve global coverage unless the EBG addresses clinical management for under-resourced populations in countries these international experts represent. What does it matter if the Indian, Algerian, or Paraguayan physician reads that EBUS is recommended for staging lung cancer but cannot offer it to their patients because they lack access to the technology? Global coverage requires that the guideline provides context-specific recommendations tailored to the varied tiers of access and expertise that characterize the diversity of global health care.

Overall, despite the substantial contributions made by EBGs to the care of patients, the issue regarding global relevance remains less whether the care of some patients around the world could be enhanced by EBGs but rather whether the needs of all patients around the world could be met by EBGs. Until this condition is satisfied, we contend that global coverage has not been achieved. Indeed, our colleagues’ statement that 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”1 suggests that they agree with us. The goal of global coverage remains a laudable aspiration.

References

Nathanson I, Ouellette DR. Point: are the CHEST guidelines global in coverage? Yes. Chest. 2015;147(1):11-13.
 
Kahn SR, Lim W, Dunn AS, et al. Prevention of VTE in nonsurgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2_suppl):e195S-e226S. [CrossRef] [PubMed]
 
Gupta D, Agarwal R, Aggarwal AN, et al; COPD Guidelines Working Group; Indian Chest Society; National College of Chest Physicians (India). Guidelines for diagnosis and management of chronic obstructive pulmonary disease: joint recommendations of Indian Chest Society and National College of Chest Physicians (India). Indian J Chest Dis Allied Sci. 2014;56(spec no):5-54.
 
Al-Moamary MS, Alhaider SA, Al-Hajjaj MS, et al. The Saudi initiative for asthma - 2012 update: guidelines for the diagnosis and management of asthma in adults and children. Ann Thorac Med. 2012;7(4):175-204. [CrossRef] [PubMed]
 

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References

Nathanson I, Ouellette DR. Point: are the CHEST guidelines global in coverage? Yes. Chest. 2015;147(1):11-13.
 
Kahn SR, Lim W, Dunn AS, et al. Prevention of VTE in nonsurgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2_suppl):e195S-e226S. [CrossRef] [PubMed]
 
Gupta D, Agarwal R, Aggarwal AN, et al; COPD Guidelines Working Group; Indian Chest Society; National College of Chest Physicians (India). Guidelines for diagnosis and management of chronic obstructive pulmonary disease: joint recommendations of Indian Chest Society and National College of Chest Physicians (India). Indian J Chest Dis Allied Sci. 2014;56(spec no):5-54.
 
Al-Moamary MS, Alhaider SA, Al-Hajjaj MS, et al. The Saudi initiative for asthma - 2012 update: guidelines for the diagnosis and management of asthma in adults and children. Ann Thorac Med. 2012;7(4):175-204. [CrossRef] [PubMed]
 
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