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Editorial |

Update of Antithrombotic Guidelines: Medical Professionalism and the Funnel of Knowledge FREE TO VIEW

John E. Heffner, MD, FCCP
Author and Funding Information

Dr Heffner is Deputy Editor of CHEST.

FINANCIAL/NONFINANCIAL DISCLOSURE: None declared.

CORRESPONDENCE TO: John E. Heffner, MD, FCCP, 530 K St, Unit 510, San Diego, CA 92101


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;149(2):293-294. doi:10.1016/j.chest.2015.12.005
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Published online

Contemporary definitions of medical professionalism recognize that clinical practice “rests on the integrity of scientific standards grounded in research evidence and the translation of evidence into practice guidelines, which define the proper use and implementation of diagnostic testing and therapeutics.” Such calls for professionalism have become as much an administrative mandate as an aspirational goal now that guideline recommendations inform the development of physician performance measures created in response to society’s recognition that health care commonly diverges from best practices and too often wastes resources, thereby driving up costs and threatening our ability to deliver effective care., Clinical practice guidelines (CPGs), therefore, represent a critical resource for improving patient care and also helping physicians succeed within reimbursement schemas (eg, pay-for-performance).

Guidelines have not always enjoyed such a preeminent role in health care. In the 1970s, for example, negligible high-quality research was available in the field of thrombotic disorders to inform decision-making for the limited diagnostic (lung scans and contrast venography for venous thrombosis) and therapeutic (unfractionated heparin, streptokinase, warfarin, and aspirin) resources available. With the explosion of scientific research in the 1980s, professional societies looked to CPGs as a way to help harried clinicians navigate complex and often conflicting primary studies to make informed medical decisions and counter administrative pressures to alter their practices in ways that might not be in their patients’ best interests. As recently as 1994, however, a survey of American College of Physicians members found that 43% of respondents believed CPGs would drive up health-care costs, 68% predicted guidelines would be used punitively to discipline physicians, and 34% believed guidelines would degrade the pleasure found in practicing medicine. Some professional societies at that time questioned the value of CPGs, especially in light of calls to increase the rigor—and consequently the cost—of methodologies for their development and implementation. With remarkable foresight, the American College of Chest Physicians (CHEST) in 2000 convened a workshop that examined the value of CPGs, decided they were worth the effort and expense, and set methodologic standards for their development and implementation. Since then, physicians have accepted CPGs as the terminus of the “knowledge funnel” through which research flows into systematic reviews and on to the development of guidelines, which are the “action” arm of science for improving clinical practice.

Fifteen years after the American College of Chest Physicians’ guideline workshop, I can think of no better way to assess the College’s success in implementing its lofty goals for CPGs then by reflecting on the remarkable history of the American College of Chest Physicians’ antithrombotic (AT) guidelines. Through nine editions spanning 30 years, the AT guidelines have convened the leading international experts on AT therapy. These experts adopted nonbiased consensus development processes, utilized rigorous methods to review existing research using trained methodologists, standardized the grading of evidence and clinical recommendations, and safeguarded the final product from commercial conflict of interests. These innovations have stimulated other professional societies to adopt more rigorous evidence-based approaches to guideline development. The latter has been an especially important side benefit of the AT guidelines, considering the historically low quality of many published CPGs.,,

Moreover, guidelines have been criticized as a Tower of Babel because multiple, often poorly constructed, overlapping, and conflicting guidelines on the same disease confuse clinical practice. However, the American College of Chest Physicians’ AT guidelines, through the sheer breadth of AT topics addressed and their authoritative methodology, have “cornered” the market on AT guidelines, which fulfills the goals of international organizations that call for harmonization of guidelines into coherent and consistent clinical recommendations. Finally, the AT guidelines were prescient in incorporating patient perspectives into shared decision-making, such as the recommended patient-physician discussions to determine the duration of warfarin therapy in managing idiopathic DVT. Observers have criticized other guidelines for too often taking the physician’s perspective solely rather than including patient wishes and values.

Thus, a new update for AT therapy begins with the publication of the first topic on Antithrombotic Therapy for VTE Disease (see page 315), in what will be a serialized publication of the newly updated AT guidelines. As a clinician interested in AT therapy and also as someone who has followed the field of guideline development and implementation closely, I—like most physicians—am eager to see what’s new. As for new management recommendations, this update of the AT guidelines is especially newsworthy. To name a few of the revised recommendations, the guidelines outline an expanded role for nonvitamin K oral anticoagulants to help physicians assess the role of these emerging therapies. An important departure from traditional management of subsegmental pulmonary emboli is offered. New recommendations are provided for the treatment of cancer-associated thrombosis.

Of equal newsworthiness is the plan to publish these guidelines online in a serialized “Living Guidelines Model.” This model will address criticisms that guidelines become outdated in 3 to 5 years, and organizations that develop guidelines lack mechanisms for updating their recommendations in synchrony with new scientific discoveries. The CHEST Guidelines Oversight Committee has again harkened to the 2000 American College of Chest Physicians’ workshop report that encouraged the College to devise processes for “frequent modification of guidelines to maintain their currency.” This new model fundamentally raises the bar for guideline development, dissemination, and implementation by focusing on specific portions of the AT guideline that require updating and will most likely alter approaches to guideline development for other professional societies in coming years.

The 2000 American College of Chest Physicians’ guidelines workshop noted that “guidelines are the substrate for experienced clinicians who interpret science with an intention to practice the art of medicine for the benefit of individual patients.” Many barriers exist, however, to the optimal translation of guideline recommendations into physician actions that improve care. There is little empiric research with regard to AT therapy specifically for determining the most effective methods to overcome these barriers and implementing AT guideline recommendations. Now that CHEST has honed its methods for guideline development, they are embarking on discovering new processes (eg, the Living Guidelines Model, mobile applications, E-learning approaches) for guideline implementation designed to turn recommendations into action and improve patient care. These efforts highlight the College’s commitment to medical professionalism and will hopefully stimulate research into whether these novel approaches for updating guidelines will improve health for patients with thrombotic disease.

Supplementary Data

Qaseem A. .Snow V. .Gosfield A. .et al Pay for performance through the lens of medical professionalism. Ann Intern Med. 2010;152:366-369 [PubMed]journal. [CrossRef] [PubMed]
 
Shaneyfelt T.M. .Mayo-Smith M.F. .Rothwangl J. . Are guidelines following guidelines? The methodological quality of clinical practice guidelines in the peer-reviewed medical literature. JAMA. 1999;281:1900-1905 [PubMed]journal. [CrossRef] [PubMed]
 
Kahn J.M. .Scales D.C. .Au D.H. .et al An official American Thoracic Society policy statement: pay-for-performance in pulmonary, critical care, and sleep medicine. Am J Respir Crit Care Med. 2010;181:752-761 [PubMed]journal. [CrossRef] [PubMed]
 
Heffner J.E. . The overarching challenge. Chest. 2000;118:1S-3S [PubMed]journal. [CrossRef] [PubMed]
 
Tunis S.R. .Hayward R.S. .Wilson M.C. .et al Internists’ attitudes about clinical practice guidelines. Ann Intern Med. 1994;120:956-963 [PubMed]journal. [CrossRef] [PubMed]
 
Heffner J.E. . Does evidence-based medicine help the development of clinical practice guidelines. Chest. 1998;113:172S-178S [PubMed]journal. [CrossRef] [PubMed]
 
Grimshaw J.M. .Schünemann H.J. .Burgers J. .et al Disseminating and implementing guidelines: article 13 in Integrating and coordinating efforts in COPD guideline development. An official ATS/ERS workshop report. Proc Am Thorac Soc. 2012;9:298-303 [PubMed]journal. [CrossRef] [PubMed]
 
Neumann I. .Karl R. .Rajpal A. .Akl E.A. .Guyatt G.H. . Experiences with a novel policy for managing conflicts of interest of guideline developers: a descriptive qualitative study. Chest. 2013;144:398-404 [PubMed]journal. [CrossRef] [PubMed]
 
Shaneyfelt T.M. .Centor R.M. . Reassessment of clinical practice guidelines: go gently into that good night. JAMA. 2009;301:868-869 [PubMed]journal. [CrossRef] [PubMed]
 
Sniderman A.D. .Furberg C.D. . Why guideline-making requires reform. JAMA. 2009;301:429-431 [PubMed]journal. [CrossRef] [PubMed]
 
Hibble A. .Kanka D. .Pencheon D. .Pooles F. . Guidelines in general practice: the new Tower of Babel? BMJ. 1998;317:862-863 [PubMed]journal. [CrossRef] [PubMed]
 
Schünemann H.J. .Woodhead M. .Anzueto A. .et al A vision statement on guideline development for respiratory disease: the example of COPD. Lancet. 2009;373:774-779 [PubMed]journal. [CrossRef] [PubMed]
 
Kearon C. .Akl E.A. .Ornelas J. .et al Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest. 2016;149:315-352 [PubMed]journal. [CrossRef] [PubMed]
 
Heffner J.E. .Alberts W.M. .Irwin R. .Wunderink R. . Translating guidelines into clinical practice: recommendations to the American College of Chest Physicians. Chest. 2000;118:70S-73S [PubMed]journal. [CrossRef] [PubMed]
 
Schünemann H.J. .Cook D. .Grimshaw J. .et al Antithrombotic and thrombolytic therapy: from evidence to application: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126:688S-696S [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Tables

References

Qaseem A. .Snow V. .Gosfield A. .et al Pay for performance through the lens of medical professionalism. Ann Intern Med. 2010;152:366-369 [PubMed]journal. [CrossRef] [PubMed]
 
Shaneyfelt T.M. .Mayo-Smith M.F. .Rothwangl J. . Are guidelines following guidelines? The methodological quality of clinical practice guidelines in the peer-reviewed medical literature. JAMA. 1999;281:1900-1905 [PubMed]journal. [CrossRef] [PubMed]
 
Kahn J.M. .Scales D.C. .Au D.H. .et al An official American Thoracic Society policy statement: pay-for-performance in pulmonary, critical care, and sleep medicine. Am J Respir Crit Care Med. 2010;181:752-761 [PubMed]journal. [CrossRef] [PubMed]
 
Heffner J.E. . The overarching challenge. Chest. 2000;118:1S-3S [PubMed]journal. [CrossRef] [PubMed]
 
Tunis S.R. .Hayward R.S. .Wilson M.C. .et al Internists’ attitudes about clinical practice guidelines. Ann Intern Med. 1994;120:956-963 [PubMed]journal. [CrossRef] [PubMed]
 
Heffner J.E. . Does evidence-based medicine help the development of clinical practice guidelines. Chest. 1998;113:172S-178S [PubMed]journal. [CrossRef] [PubMed]
 
Grimshaw J.M. .Schünemann H.J. .Burgers J. .et al Disseminating and implementing guidelines: article 13 in Integrating and coordinating efforts in COPD guideline development. An official ATS/ERS workshop report. Proc Am Thorac Soc. 2012;9:298-303 [PubMed]journal. [CrossRef] [PubMed]
 
Neumann I. .Karl R. .Rajpal A. .Akl E.A. .Guyatt G.H. . Experiences with a novel policy for managing conflicts of interest of guideline developers: a descriptive qualitative study. Chest. 2013;144:398-404 [PubMed]journal. [CrossRef] [PubMed]
 
Shaneyfelt T.M. .Centor R.M. . Reassessment of clinical practice guidelines: go gently into that good night. JAMA. 2009;301:868-869 [PubMed]journal. [CrossRef] [PubMed]
 
Sniderman A.D. .Furberg C.D. . Why guideline-making requires reform. JAMA. 2009;301:429-431 [PubMed]journal. [CrossRef] [PubMed]
 
Hibble A. .Kanka D. .Pencheon D. .Pooles F. . Guidelines in general practice: the new Tower of Babel? BMJ. 1998;317:862-863 [PubMed]journal. [CrossRef] [PubMed]
 
Schünemann H.J. .Woodhead M. .Anzueto A. .et al A vision statement on guideline development for respiratory disease: the example of COPD. Lancet. 2009;373:774-779 [PubMed]journal. [CrossRef] [PubMed]
 
Kearon C. .Akl E.A. .Ornelas J. .et al Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest. 2016;149:315-352 [PubMed]journal. [CrossRef] [PubMed]
 
Heffner J.E. .Alberts W.M. .Irwin R. .Wunderink R. . Translating guidelines into clinical practice: recommendations to the American College of Chest Physicians. Chest. 2000;118:70S-73S [PubMed]journal. [CrossRef] [PubMed]
 
Schünemann H.J. .Cook D. .Grimshaw J. .et al Antithrombotic and thrombolytic therapy: from evidence to application: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126:688S-696S [PubMed]journal. [CrossRef] [PubMed]
 
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