Making the shift to evidence-based clinical practice guidelines

November 25, 2012

By Stephen C. Miller, O.D., and John F. Amos, O.D., members of the Evidence-Based Optometry Committee

Clinical research is a cornerstone of medical care. The results of clinical studies help determine the most effective patient care. But not all studies can be relied on to guide appropriate clinical decision-making.

How can clinicians handle conflicts in research results or clinical recommendations? When studies draw different conclusions or guideline recommendations vary, how can effective patient care strategies be determined?

One answer is evidence-based optometry and the development of evidence-based clinical practice guidelines. And the AOA needs the help of its members in their development.

Clinical practice guidelines aren’t new. If you were practicing optometry in the mid-1990s, you probably remember receiving the first of what would become a series of 20 optometric practice guidelines developed by the AOA.

These guidelines have been regularly reviewed and revised as needed since their initial development to reflect the results of new research in diagnostic and treatment approaches.

They continue to be a valuable resource for clinicians and policymakers today. Copies of all the guidelines can be accessed on the AOA website (www.aoa.org/x4813.xml).

However, a new phase in clinical practice guideline development is being driven by the Institute of Medicine (IOM) of the National Academy of Sciences.

A provision in the Medicare Improvements for Patients and Providers Act of 2008 directed the IOM to develop rigorous new standards for the development of evidence-based guidelines.

These standards call for developing guidelines through a process that evaluates the quality of available research and ranks the strength of clinical recommendations based on that research.

According to the Agency for Healthcare Research and Quality (AHRQ) of IOM, to be evidence-based, guidelines must be:

  • Based on a systematic review of the existing evidence;
  • Developed by a knowledgeable, multidisciplinary panel of experts and representatives from key affected groups;
  • Based on an explicit and transparent development process to minimize bias and conflicts of interest;
  • Rated for both the quality of evidence and the strength of recommendations; and
  • Reviewed every two years and revised when new evidence warrants.

While all the Optometric Clinical Practice Guidelines that have been developed are based on a review of the available research evidence, this new guideline development process puts increased emphasis on the evaluation of the strength of the research on which clinical practice recommendations are made.

New guidelines must attempt to quantify the extent to which clinicians can rely on both the patient care recommendations made and the research on which they are based.

To meet this more rigorous standard, the AOA, through its Evidence-Based Optometry Committee, has begun the process of developing new evidence-based Clinical Practice Guidelines. The first guideline to be addressed is “Care of the Patient with Diabetes Mellitus.”

Teams of optometrists, medical specialists, patient advocates, and other stakeholders will participate in the development of the new evidence-based optometric guidelines. They will:

  • Write the clinical questions that need to be answered relating to the diagnosis and treatment of the condition being addressed by the guideline;
  • Oversee a thorough search of the published literature;
  • Read each available research study and evaluate its strength;
  • Develop and rank clinical recommendations based on the strength of the research; and
  • Identify gaps in research that need to be addressed by future research.

Completed evidence-based optometric guidelines will bring together, in one place, the most current recommendations for patient care.

In addition, they will provide an evaluation of the strength of evidence supporting each clinical recommendation to better guide practitioners in their clinical decision-making and patient care.

Only evidence-based guidelines that meet the standards mandated by IOM will be accepted for inclusion in the National Guidelines Clearinghouse, a national governmental database that currently includes nearly 2700 guidelines, including those previously developed by the AOA.

The AOA would like to invite you to get involved with this new and exciting process. If you are interested in participating on a multidisciplinary panel of experts for future guidelines, contact Danette Miller, AOA manager of Quality Improvement, at 314-983-4155 or via email at DMiller@AOA.org.

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