Clinical Practice Guidelines – Burden or Boon?

The American Academy of Orthopedic Surgeons (AAOS) has released a new Clinical Practice Guideline on the Diagnosis and Treatment of Carpal Tunnel Syndrome. This document replaces earlier ones on diagnosis, published in 2007, and treatment, which appeared in 2008. There was a widespread perception that the recommendations made in the previous guidelines were weak and did not contribute substantively to the care of patients with carpal tunnel syndrome (CTS). In fact, neither of these guidelines were endorsed by the American Society for Surgery of the Hand (ASSH). Given that history, is there any reason to believe that the current guideline will be any different?

In the spirit of full disclosure, I acknowledge that I was the chairman of the current guideline workgroup, and I was joined in that activity by two ASSH members, one of whom was the vice-chair. The AAOS oversight role was also filled by a member of the ASSH. Because of that fact, I won’t be standing on my soapbox as editor of JHS to try and persuade anybody to accept these recommendations. In the coming months there will be some invited commentary on the new guideline in The Hand Surgery Landscape, which I hope will spark discussion among Journal readers. Instead, what I would like to briefly address is the process of guideline development and reflect on what place these documents have in our day-to-day practice as hand surgeons.

It is a given that we all seek to do the best possible for our patients and that we try use our judgment to give them advice that will benefit them. It is also equally clear that we do this in an increasingly difficult environment of regulation and oversight, not to mention one that is also characterized by decreasing reimbursement. Taken in this context, a practice guideline might seem an extraneous imposition which limits the choices we might offer our patients simply because of the potential risk, both medicolegal and financial, of appearing to be outside the dictum of an influential professional organization like AAOS. But I don’t think that this is the correct analysis, and although dealing with a guideline might seem an unworthy burden, it is possible that, in the long run, it can be a substantial benefit to clinicians and their patients.

There are a few reasons for taking this view. Let’s start with the process of guideline development. The working group crafting the recommendations does so within a careful and standardized framework that prevents any personal agenda on the part of a single individual from dominating. The recommendations themselves have to be discussed within the working group, and the final version of these has to be agreed upon by consensus of the working group members. In the case of the recent carpal tunnel syndrome guideline the panelists were from all the stakeholder groups: orthopedic surgery, plastic surgery, physiatry, neurology, radiology and allied health. They are supported by a team of evidence analysts who extract the data from papers meeting stringent evidence criteria for inclusion. The result of this effort is that the recommendations of any practice guideline are based only on the highest levels of evidence available. Where there is no evidence, a recommendation simply cannot be made. Is the evidence always correct? Not necessarily, but the guidelines approximate the best distillation of what is most reliably known about the topic. Can the evidence change over time? Of course, and the best guidelines make suggestions about what direction future research might take.

So, if the recommendations are based on the best evidence, they would seemingly trump the judgment of the clinician – and of course this view is the one that regulators, payers and lawyers may choose to adopt when it suits their special interests. While there is no doubt that this reality may complicate our practices, it cannot be strongly enough emphasized that a guideline is intended to do just that – guide, not dictate. Having said that, where evidence appears to contradict experience, it is not unreasonable to suggest that some introspection by clinicians might also be appropriate, in case conventional wisdom has gradually turned into ritual. The bottom line is that clinical practice guidelines will be an increasingly important reality with which doctors will have to contend in the future. Engaging – even embracing – the guideline process may be a key consideration to maintaining control over our practices because, like it or not, we are not going back to practice dictated by experience alone. The focus on evidence – understanding, interpreting and refining it – can only benefit our patients and lead to a greater understanding of their problems, and that is a good thing for everyone.

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Brent Graham practices in Toronto. He loves all things related to the guitar and to the Toronto Raptors. Dr. Graham is the Editor-in-Chief of the Journal of Hand Surgery.

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