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Editorial |

It’s Not Rio but CHEST’s Cough Guidelines Win Gold FREE TO VIEW

Ian T. Nathanson, MD, FCCP
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: The author has reported to CHEST the following: I. T. N. is the Section Editor for the Evidence-Based Medicine section.

Health Services, Humana, Inc., Orlando, FL

CORRESPONDENCE TO: Ian T. Nathanson, MD, FCCP, 3501 SW 160 Ave, Miramar, FL 33027


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


Chest. 2016;150(4):761-762. doi:10.1016/j.chest.2016.06.034
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Published online

The recent Olympiad reminds us of the herculean efforts required by athletes to become “best in class.” The same can be said for anyone trying to achieve the pinnacle of success, including those of us in the field of medicine. Therefore, it is fitting that in this Olympic year, the American College of Chest Physicians (CHEST) cough guidelines have won a gold medal.

FOR RELATED ARTICLE SEE PAGE 777

In this month’s issue of CHEST, Jiang et al report their results of a critical review of clinical practice guidelines for cough. These researchers systematically evaluated 15 cough guidelines published from 2004 through 2016. Of these, five of 15 (33.3%) were developed by international organizations or more than one country, and the remaining came from countries in Europe and Asia. In addition, 13 of 15 (86.7%) were written by professional societies. Such an assortment of guidelines clearly represents the efforts used by clinical leaders throughout much of the world to develop recommendations to manage patients with cough.

The methods used in this paper were robust. Two pulmonologists, an epidemiologist, and a methodologist compared the various guidelines using the validated and highly respected Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument., AGREE II contains 23 items divided into six domains followed by two overall assessment items. The six domains consist of scope, purpose, stakeholder involvement, rigor of development, clarity of presentation applicability, and editorial independence. The reported intraclass correlation coefficients (0.82; 95% CI, 0.79-0.85) reflected very good agreement among the four evaluators. Just how well did CHEST’s cough guidelines do? Of the 15 guidelines that met original criteria for entry into the study, CHEST cough guidelines scored higher than the other guidelines in every domain. Furthermore, it was the only guideline classified as strongly recommended. Six other guidelines were classified as recommended with modifications, and eight were not recommended. In essence, CHEST cough guidelines were “best in class.”

As part of its strategic plan CHEST makes major efforts to produce relevant evidence-based guidelines that help clinicians with their decision-making. Any member of the College can suggest a topic for a guideline, but actually creating a guideline is a complex process. The Guidelines Oversight Committee (GOC) bears responsibility for producing guidelines and deciding when they need to be updated or retired. Once the GOC chooses a topic, it searches for content experts who can formulate population, intervention, comparators, and outcomes questions that will focus the guideline into discrete sections that serve as the basis for final recommendations. Next, the GOC selects panelists, including methodologists, front-line clinicians and patient advocates, to actually write the guideline. All panelists must complete conflict of interest disclosures that are reviewed by the professional standards committee, which can approve, approve with management, or disapprove a proposed panelist’s participation. The final guidelines panel includes experts from various parts of the world who review, grade, and discuss the available evidence before writing their recommendations. As the process matures, guideline developers will also look at the intervention fidelity of available research. Before being deemed ready for publication, the entire guideline undergoes separate review processes by the GOC, the Board of Regents, and the journal CHEST. Implementing these recommendations eventually falls to the local community, although the usefulness of these guidelines by clinicians outside of North America has been the subject of some debate.,

We need to acknowledge the commitments made by panelists who review the medical literature, discuss the evidence, and write the guideline recommendations and supporting documents. Panelists participate without compensation while maintaining their “day jobs,” but failing to meet their obligations can jeopardize the entire guideline. Leading this team is the chair of the guideline whose responsibility includes meeting deadlines, writing his or her own recommendations, reviewing other recommendations, and sometimes rewriting entire sections. Chairs do not just herd cats; they master the chaos theory.

This background brings us back to the CHEST cough guideline. The chair of the cough guideline cited by Jiang et al is Richard Irwin, MD, Master FCCP. To be completely transparent, Dr Irwin is also the Editor-in-Chief of CHEST but had nothing to do with the review process of this manuscript when it was submitted to CHEST. He appropriately recused himself and let others decide if the paper should be accepted. In light of the seemingly endless causes and treatments of cough, Dr Irwin and his guideline panel managed to put together a document that all clinicians can use. Furthermore, they continue to update their recommendations.

Is it an exaggeration to say CHEST wins gold? Perhaps, but I think not. Athletes competing at the highest levels are not solo practitioners. They have teams of support personnel to assist them. The same is true for the medical field. We deliver care as a team. The cough guideline team delivered better than other cough guideline teams, and their efforts will trickle down to improving the lives of untold millions of people worldwide. Although we will not be physically draping a gold medal over the necks of the guideline panelists, we can certainly applaud them for what they have done to enrich our understanding of this common problem and to guide us when we care for patients.

References

Irwin R.S. .French C.T. .Lewis S.Z. .et al Overview of the management of cough: CHEST Guideline and Expert Panel Report. Chest. 2014;146:885-889 [PubMed]journal. [CrossRef] [PubMed]
 
Jiang M. .Guan W. .Fang Z. .et al A critical review of the quality of cough clinical practice guidelines. Chest. 2016;150:777-788 [PubMed]journal
 
AGREE Next Steps Consortium. The AGREE II instrument. 2009.www.agreetrust.org. Accessed May 22, 2016.
 
Brouwers M.C. .Kho M.E. .Browman G.P. .et al AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ. 2010;182:E839-E842 [PubMed]journal. [CrossRef] [PubMed]
 
French C.T. .Diekemper R.L. .Irwin R.S. .et al Assessment of intervention fidelity and recommendations for researchers conducting studies on the diagnosis and treatment of chronic cough in the adult. Chest. 2015;148:32-54 [PubMed]journal. [CrossRef] [PubMed]
 
Nathanson I. .Ouellette D.R. . Point: are the CHEST guidelines global in coverage? Yes. Chest. 2015;147:11-13 [PubMed]journal. [CrossRef] [PubMed]
 
Mehta A.C. .Banga A. .Stoller J.K. . Counterpoint: are the CHEST guidelines global in coverage? No. Chest. 2015;147:13-15 [PubMed]journal. [CrossRef] [PubMed]
 

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References

Irwin R.S. .French C.T. .Lewis S.Z. .et al Overview of the management of cough: CHEST Guideline and Expert Panel Report. Chest. 2014;146:885-889 [PubMed]journal. [CrossRef] [PubMed]
 
Jiang M. .Guan W. .Fang Z. .et al A critical review of the quality of cough clinical practice guidelines. Chest. 2016;150:777-788 [PubMed]journal
 
AGREE Next Steps Consortium. The AGREE II instrument. 2009.www.agreetrust.org. Accessed May 22, 2016.
 
Brouwers M.C. .Kho M.E. .Browman G.P. .et al AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ. 2010;182:E839-E842 [PubMed]journal. [CrossRef] [PubMed]
 
French C.T. .Diekemper R.L. .Irwin R.S. .et al Assessment of intervention fidelity and recommendations for researchers conducting studies on the diagnosis and treatment of chronic cough in the adult. Chest. 2015;148:32-54 [PubMed]journal. [CrossRef] [PubMed]
 
Nathanson I. .Ouellette D.R. . Point: are the CHEST guidelines global in coverage? Yes. Chest. 2015;147:11-13 [PubMed]journal. [CrossRef] [PubMed]
 
Mehta A.C. .Banga A. .Stoller J.K. . Counterpoint: are the CHEST guidelines global in coverage? No. Chest. 2015;147:13-15 [PubMed]journal. [CrossRef] [PubMed]
 
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