AAOS Bulletin - February, 2005

AAOS is committed to evidence-based guidelines

By Michael J. Goldberg, MD, and Belinda Duszynski

At its October 2004 meeting, the AAOS Board of Directors approved a new Position Statement on Evidence-Based Guidelines, developed by the Evidence-Based Practice Committee. The position statement acknowledges the importance of developing and implementing guidelines that are based on the best available evidence to assist the practitioner in the quest to improve patient care. This article expands on the belief statements in that position statement.

Closing the gap

The AAOS believes that closing the gap between knowledge and practice will improve clinical performance and the quality of care.

The Institute of Medicine’s 2001 report Crossing the Quality Chasm1 clearly identifies a gap between knowledge and practice. Driven to improve the quality of care and reduce disparities, the AAOS has turned to the development of clinical practice guidelines.

In the late 1990s, proponents of “evidence-based medicine” began to educate guideline developers about the importance of the evidence base. The evidence base serves as the cornerstone for good clinical decision-making and good patient care. Thus, it is important to create evidence-based guidelines. About this time, the AAOS began to incorporate an evidence-based methodology into its guideline development program.

Best research

The AAOS is committed to ensuring that guidelines used in the care of orthopaedic patients are based on the best research evidence available.

The foundation for the best clinical practice of medicine evolves from published, peer-reviewed evidence. Yet the sheer volume of this information presents an almost insurmountable problem to the practicing surgeon. Evidence-based practice guidelines serve to assist the practicing orthopaedic surgeon in the quest to improve patient care by evaluating and consolidating the relevant literature, assigning a level of evidence based on research methodology and indicating the strength of the recommendation for treatment options.

Technology assessment

The AAOS believes that the evidence for new technologies must be carefully assessed, and encourages all practitioners to objectively evaluate their own surgical skills prior to implementing new technologies.

Evidence analysis is not only applicable to guideline development, but also to the world of technology assessment. Studies of new technologies should be evaluated as to their levels of evidence, and practitioners should carefully review the evidence and determine the appropriateness of implementing new technologies after a critical assessment of their own surgical skills and their patients’ personal values.

Expert opinion

While the AAOS acknowledges that in absence of high quality evidence, expert consensus is integral to developing guidelines, it is imperative that the methodology for incorporating expert opinion be explicitly delineated in the guideline.

Broad acceptance of guidelines is more likely if the process by which the guidelines are developed is transparent and explicit. Experts in the evidence-based practice arena recognize how difficult it is to develop a guideline when the quality of the literature is not high (e.g., no randomized controlled clinical trials nor case control series), and acknowledge that in such instances, expert opinion does play a supplementary role. It is critical, however, that the way expert opinion is to be weighed and utilized in the absence of high quality evidence be explicitly delineated at the outset.

Performance measures

With the current trend toward developing physician performance measures for quality improvement and accountability, it must be remembered that evidence-based performance measures can only be derived from evidence-based guidelines.

The AAOS supports the development of evidence-based practice guidelines by the Academy and other organizations, and encourages the implementation of evidence-based guidelines by regulatory and accrediting agencies to improve physician performance and ensure the quality of care for orthopaedic patients.

The AAOS believes that implementation of evidence-based guidelines will result in improved quality of care for patients by reducing over- and under-utilization of diagnostic tests and treatment modalities.

Evidence-based practice, as defined by Sackett2, consists of “the integration of best research evidence with clinical expertise and patient values.” Evidence-based practice guidelines represent a logical progression through the diagnosis and treatment of a clinical problem based on the most current evidence that has been evaluated as to levels of evidence. The guidelines should represent a reasonable approach to the problem that allows for a wide variance in practice style, based on the practitioner’s clinical expertise and experience, as well as the values of the patient.

Cooperation

The AAOS will work with a broad range of public and private agencies, including governmental agencies, medical professionals and others, to ensure implementation of evidence-based practice to improve the quality of care for orthopaedic patients.

References

1. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. National Academy Press, 2001.

2. Sackett DL, Straus SE, Richardson WS, et al. Evidence-based medicine. How to practice and teach EBM, 2nd ed. London: Churchill Livingstone, 2000.

Michael J. Goldberg, MD, is orthopaedist-in-chief at the Tufts-New England Medical Center and chair of the AAOS Evidence-Based Practice Committee. He can be reached at mailto:mgoldberg@tufts-nemc.org

Belinda Duszynski is an independent consultant working with the AAOS Evidence-Based Practice Committee.


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