January 2014 Pulmonary Journal Club: Interventional Guidelines

Feuerstein JD, Akbari M, Gifford AE, Hurley CM, Leffler DA, Sheth SG, Cheifetz AS. Systematic analysis underlying the quality of the scientific evidence and conflicts of interest in interventional medicine subspecialty guidelines. Mayo Clin Proc. 2014;89(1):16-24. [CrossRef] [PubMed] (For editorial comment click here)

A few years ago a colleague and I were discussing the shape of healthcare in the USA.  One of the comments that was made was "that despite the high costs within our system, that at least there was some standardization in the treatment of certain diseases, for example, receiving Aspirin for an acute myocardial infarction".  Guidelines exist to ensure that for certain conditions a standard of care is practiced. When guidelines start to become a measuring stick for what is now considered best practice…..then it our responsibility to ensure that guidelines are rooted on high quality evidence. This paper reviewed the validity of guidelines published and practiced by several of the interventional medical societies including the American Association for Bronchology and Interventional Pulmonology (AABIP), American Society of Diagnostic and Interventional Nephrology (ASDIN), American Society For Gastrointestinal Endoscopy (ASGE) and the Society for Cardiovascular Angiography and Interventions (SCAI).

A total of 153 interventional guidelines were evaluated between November 2012 and January 2013. Each guideline was reviewed to determine the level of evidence and convicts of interest. The large majority of the guidelines reviewed were from the ASGE (67) and SCAI (80). The results showed that out of the 153 guidelines reviewed that only 69 (46%) had a grades of evidence associated with them. The levels of evidence for most guidelines were grade B or C (expert Opinion). Nearly 50% of recommendations were based on expert opinion whereas Only 11% of the recommendations  were validated by Grade A evidence. When looking at conflict of interest only 57 of the guidelines revealed a conflict of interest out of which 52 (91%) revealed that a conflict of interest existed. Most of the guidelines (62%)  failed to report on whether any conflict of interest existed.

Practice guidelines should exist to improve the standard of care wince they have been based on repeated validation and held to the highest level of evidence. We are now to often seeing guidelines set forth based on weak evidence and then tied into best practice measures. It is our duty as clinicians, scientists, and educators, to ensure that practice models are based on the best interest of the patient which can any be met by rigorous and repeated testing and the highest grade of evidence. Setting forth guidelines and recommendations based on expert opinion may be of benefit when no other studies exist but the level of evidence on these practices should be made clear and conflicts of interest be reported. In our haste to standardize healthcare practices we have become lax to include recommendations that are more in the interest of the institutions rather that for the patient.

Manoj Mathew MD FCCP MCCM

Reference as: Mathew M. January 2014 pulmonary journal club: interventional guidelines. Southwest J Pulm Crit Care. 2014;8(1):70. doi: http://dx.doi.org/10.13175/swjpcc007-14 PDF

May, 2011 Pulmonary Journal Club

Attridge RT, Frei CR, Restrepo MI, Lawson KA, Ryan L, Pugh MJV, Anzueto A, Mortensen EM. Guideline-Concordant Therapy and Outcomes in Healthcare-Associated Pneumonia. E Resp J Published online before print March 24, 2011, doi: 10.1183/​09031936.00141110 (Click here for abstract)

Reference as: Mathew M. May 2011 pulmonary journal club. Southwest J Pulm Crit Care 2011;2:65-66. (Click here for PDF version of journal club)

     The use of guidelines in patient management has not only become standard of care but often the benchmark by which quality of care has been measured.  Certain guidelines have shown clear benefit as seen with the management of acute myocardial or stroke. Other guidelines have been met with reluctance given the level of evidence reinforcing them.  This study by Attridge et al. looks at the effect of implementing and following guidelines in the management of healthcare associated pneumonia (HCAP) within the VA system.

     In 2005 a combined effort from the ATS and IDSA created a new clinical entity known as Health Care Associated Pneumonia (HCAP) (1). This entity is believed to be different from community acquired pneumonia based on the pathogens involved, i.e., methicillin resistant Staphylococcus aureus and Pseudomonas versus Streptococcus. The guidelines created in 2005 defined HCAP as an entity in which the patient was hospitalized > 48h within the past 90 days, on dialysis, on home infusions, a current nursing home resident, undergoing home wound care, or in contact with a family member with multi-drug resistant pathogen. The inclusion of any one of these criteria would categorize the patient as having the diagnosis of HCAP and warrant treatment as such.     

     This study was a large retrospective cohort study done within the VA healthcare system. After inclusion and exclusion criteria, a total of 15071 patients were included and divided into 3 groups.   Patients that met HCAP criteria and that were treated as such, patients that met HCAP criteria but that were treated as community acquired pneumonia (CAP) and patients that met HCAP criteria that were treated via a non-guideline approach. The primary outcomes were 30 day mortality and length of stay.

The results of the study are shown below:

The data demonstrated that compliance with the guidelines resulted in a higher 30 day mortality without change in  length of stay when patients were treated under HCAP guidelines.

     The main strengths of the study are the large patient size and relative uniformity in patient characteristics. The study did have several limitations. The main limitation was that the method of sputum collection outlined in original 2005 guideline to guide antibiotic therapy was not met. Only 9% of all patients had a positive culture, this value is lower than prior reported studies. If the premise of HCAP as a separate entity based on the unique pathogens isolated is to hold valid; then an aggressive approach to sampling of the respiratory tract should be made. The study also reinvigorates the debate on implementing guidelines when the data is still sparse. Unfortunately, guidelines often become surrogate benchmarks for quality assurance. If practice measures are based on whether guidelines are followed than we need to do a better job scrutinizing the data before guidelines are set forth.

Manoj Mathew, MD, FCCP, MCCM

References

1. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171: 388-416.