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Chapter 26.2: How to Interpret and Use a Clinical Practice Guideline or Recommendation

Romina Brignardello-Petersen; Alonso Carrasco-Labra; Gordon H. Guyatt

Clinical Scenario

CLINICAL SCENARIO

A family physician is seeing a 25-year-old woman with seasonal allergic rhinitis. This year, her nasal and ocular symptoms are severe enough that she is seeking medical care. After the physician and patient discuss the treatment options, the physician initiates single therapy with an intranasal corticosteroid but is aware of an alternative treatment, an intranasal H1 antihistamine.

To inform her decision, the physician searches for an evidence-based recommendation and finds the following: “In patients with seasonal allergic rhinitis, we suggest an intranasal corticosteroid rather than an intranasal antihistamine (conditional recommendation, moderate certainty of evidence).”1

The physician explains to the patient that a conditional recommendation means that the therapy is likely to be the best choice, but because of the patient’s particular situation, it may not be. The physician prescribes an intranasal corticosteroid but explains that she will follow up with the patient with a telephone call after she reads further about this recommendation.

Clinical Practice Guidelines

In treating patients, clinicians frequently rely on recommendations from clinical practice guidelines that can be defined as statements that include recommendations intended to optimize patient care. In the guideline development process, a panel formulates recommendation questions that guide the retrieval of evidence that informs the recommendations. Typically, methods of guideline development, a summary of the supporting evidence, and a justification of the panel’s decisions accompany the recommendations. This documentation can inform clinicians interested in ascertaining the trustworthiness of the guideline development process and fully understanding the recommendations. Building on prior Users’ Guides addressing guidelines,2-6 this Users’ Guide provides suggestions for understanding guideline methods and recommendations for clinicians seeking direction in evaluating clinical practice guidelines for potential use in their practice.

Using Recommendations From Guidelines

Box 26.2-1 presents direction for using recommendations from clinical practice guidelines.

BOX 26.2-1

Users’ Guides for Assessing a Clinical Guideline Recommendation

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BOX 26.2-1

Users’ Guides for Assessing a Clinical Guideline Recommendation

  1. Is the recommendation clear and actionable?

    1. Are the patients, intervention, alternatives, and recommended action clear?

    2. Is the strength of the recommendation clear?

  2. Was the evidence summarized with rigorous systematic review methods?

  3. Did the guideline panel consider all outcomes important to patients?

  4. Did the panel make appropriate judgments in the interpretation of the evidence and the decision of the final recommendation?

    1. Did the panel appropriately consider the magnitude of effect and the relative importance of the outcomes?

    2. Did the panel consider all relevant factors for formulating recommendations?

    3. Is the strength of the recommendation appropriate?

    4. Did the panel avoid having conflicts of interest influence their judgments?

  5. Does the recommendation apply to a specific patient?

    1. Are there any important differences between the recommendation question and the clinical question of the patient?

    2. Do any of the contextual factors that have an important bearing in the recommendation differ in the patient’s ...

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