SPMM Guidelines

Recommendations &
Guidelines
!
While&tackling&a&clinical&problem,&one&may&be&guided&by&protocols&or&guidelines.&Protocols&carry&a&sense&of&
strict&adherence&being&required;&guidelines&are&recommendations&based&on&evidence.&
Treatment!recommendations&can&be&of&two&types&
1. Decision&analysis&trees&
2. Clinical&guidelines&
Steps&to&be&followed&in&producing&a&treatment&recommendation:&
1.Defining&the&decision&(&e.g.&decision&to&switch&antipsychotics&when&first&episode&of&psychosis&is&not&
controlled&even&after&12&weeks&of&treatment)&
2. Specify&the&possible&outcomes&(control&of&symptoms,&no&effect&of&a&switch,&an&increase&in&side&
effects,&noncompliance,&occurrence&of&depression,&etc.).&
3. Using&available&evidence&to&specify&the&link&between&listed&options&and&outcomes.&(Olanzapine&
causes&weight&gain,&lesser&dropout&rate&for&olanzapine&and&depots&etc…)&
4. Incorporate&values/value&judgements&to&decide&on&optimal&course&of&action&(female&patient,&poor&
lifestyle&–&weight&gain&is&an&important&problem,&etc.)&
5. Consider&local&circumstances&including&resource&availability&and&modify&action&if&needed&(no&depot&
clinics&locally,&no&CPNs,&etc.).&
Decision!analysis&refers&to&the&provision&of&formal&structure&to&the&process&of&decision&making.&This&is&
represented&as&a&
flowchart&or&tree&where&
on&the&left&side&decision&
to&be&analysed&is&
placed;&options&are&
branched&out&in&the&
centre,&and&clinical&
outcomes&are&placed&on&
the&right.&&
&
!
Decision chart: The&squares&on&the&left&are&called&decision&nodes&while&the&circles&on&the&right&are&called&chance&
nodes.&Once&the&analyst&has&drawn&the&tree&he/she&must&generate&quantitative&estimates&of&the&likelihood&of&events& !
or&probabilities&–&ranging&from&0&–impossible&to&1&–&absolutely&certain.&Then&the&analyst&places&a&utility&value&on&
each&of&the&final&outcome&from&0&–&death&to&1&–&full&health&(can&be&calculated&using&QALYs&etc).&In&the&final&step&the& !
total&value&of&each&decision&is&calculated&by&cross&product&of&utility&and&probability&with&summing&of&individual&
outcomes.&Comparing&the&final&values&one&can&decide&which&the&best&course&of&action&is.&Surgery 2003; 133:1-4
!
Practice!guidelines:!
!These&are&usually&generated&by&a&panel&of&stakeholders&(e.g.&NICE).&&
!Guidelines&based&on&same&evidence&base&may&vary&in&recommendations.&This&is&because&apart&from&being&
evidence&based,&guidance&is&also&often&value&based,&and&local&availability&(cost)&based.&
!One&very&important&step&in&generating&guidelines&is&having&a&systematically&reviewed&base&of&evidence&
on&which&recommendations&can&be&built.&
© SPMM Course
!An&explicit&statement&of&values&must&be&present&in&a&proper&guideline.&(See&NICE&guideline&summaries&–&
these&values&and&preferences&get&highlighted&in&background&of&most&guidelines)&
!Note&that&it&is&not&imperative&that&a&National&guideline&will&suit&every&local&practice;&hence&the&need&for&
local&adaptations.&
!In&order&to&check&if&guidelines&are&valid&we&can&ask&4&questions;&
1. Did&all&relevant&patient&groups,&management&options&and&outcomes&get&considered?&
2. Is&there&a&proper&systematic&review?&
3. Is&there&an&appropriate&specification&of&values&and&preferences&associated&with&outcomes?&
4. Do&the&authors&indicate&the&strength&of&recommendations?&
The Hierarchy of evidence based on the Oxford Centre for Evidence-based Medicine Levels of
Evidence (May 2001) is as follows:
I Evidence obtained from a systematic review of all relevant randomised control trials.
II Evidence obtained from at least one properly designed randomised control trial.
III-1 Evidence obtained from well-designed pseudo-randomised controlled trials (alternate
allocation or some other method).
III-2 Evidence obtained from comparative studies (including systematic reviews of such studies)
with concurrent controls and allocation not randomised, cohort studies, case-control studies, or
interrupted time series with a control group.
III-3 Evidence obtained from comparative studies with historical control, two or more single–arm
studies, or interrupted time series without a parallel control group.
IV Evidence obtained from case-series, either post-test or pre-test and post-test.
V Expert opinion without a critical appraisal, or based on physiology, bench research, or
historically based clinical principles.
Usefulness of guidelines could be determined by asking three questions:
1. Who developed them?

2. How where they disseminated?
3. How were they implemented?
The answers are; (Modified from Grimshaw & Russell 1993)
Effectiveness of How were they How were they How were they implemented?
guidelines developed? disseminated?
Highly effective Developed by those who Specific educational Patient-specific reminder during
will use them intervention e.g. consultation e.g. filed in the notes,
focused meeting, etc.
learning package with
credits
Above average Intermediate – modified Continuing medical Patient-specific feedback

effectiveness national or external education e.g. lecture,
guidelines lunch time meeting
Below average External, not by those who Mailing target groups General feedback e.g. gross audit
use them but still local
Very low External, national Publishing in a journal. General reminder

effectiveness guidelines
Guyatt, G & Rennie, D (ed). User’s guides to the medical literature; a manual for evidence-based clinical
practice. Page 175-196.AMA Press, 2002.
Grimshaw & Russell (1993) Effect of clinical guidelines on the medical practice. The Lancet 342, 1317-1322
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Recommendations &

1. Who developed them?

Above average Intermediate – modified Continuing medical Patient-specific feedback

Very low External, national Publishing in a journal. General reminder

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