The New Iraqi Journal of Medicine 2009 ; 5 (3): 87 -90 Perspectives

The use of Medical Guidelines in

Yasseen Ahmed Abass, Director * Aamir Jalal Al Mosawi, Consultant physician* Ohan Faraj Yonan, Director research section* Bassim G Anton, Director knowledge management section *Training and Development Center Iraqi Ministry of Health

Evidence-based medicine and clinical documents or statements to assist practice guidelines have become patients and practitioners in decisions increasingly salient to the international about appropriate health care for specific health care community in the 1990s. Key clinical circumstances [2]. issues in in this period can be categorized as costs and access to Modern guidelines: Such documents care, quality of and satisfaction with have been in use for thousands of years care, accountability for value in health during the entire . care, and public health and education. However, in contrast to previous The use of guidelines has become one approaches, which were often based on of the standards of the practice of tradition or authority, modern medical medicine worldwide. Despite that we are guidelines are based on an examination not universally and widely using of current evidence within the paradigm guidelines in our medical practice in of evidence-based medicine. They Iraq. usually include summarized consensus Many of the research findings and statements, but unlike the latter, they guidelines are not applied in Iraq. Some also address practical issues. times these guidelines are known but they are not translated into daily Modern clinical guidelines briefly practice. Therefore many patients don’t identify, summarize and evaluate the receive the care recommended by best evidence and most current data internationally recognized scientific about prevention, diagnosis, and authorities. prognosis, therapy including dosage of , risk/benefit and cost- The rapid yearly proliferation of medical effectiveness. Then they define the most knowledge has made the implementation important questions related to clinical of evidence and guidelines in daily practice and identify all possible practice complex [1]. decision options and their outcomes. Some guidelines contain decision or A medical practice guideline (also computation algorithms to be followed. called a clinical guideline, clinical Thus, they integrate the identified protocol or clinical practice guideline) is decision points and respective courses of defined as systematically-developed action to the clinical judgment and

87 experience of practitioners. Many Evolution of the concept guidelines place the treatment alternatives into classes to help providers The guideline-based approach to in deciding which treatment to use. healthcare is a relatively recent one and has originated in the United States in the Objectives of the use of guidelines 1990s. Guidelines are usually produced at national or international levels by 1- Guiding decisions and criteria medical associations or governmental regarding diagnosis, management, and bodies, such as the US Agency for treatment in specific areas of healthcare. Healthcare Research and Quality.

2-Standardize medical care, to raise Synthesis of Guidelines quality of care by reducing variations in practice and to control costs through Practice guidelines are rapidly becoming more-efficient use of health care preferred decision-making resources in resources, to reduce several kinds of risk medicine, as advances in technology and (to the patient, to the healthcare pharmaceutics continue to expand. An provider). evidence-based approach to the development of practice guidelines It has been demonstrated repeatedly that serves to anchor healthcare policy to the use of guidelines by healthcare scientific documentation, and in providers such as is an conjunction with practitioner opinion effective way of achieving the objectives can provide a powerful and practical listed above, although they are not the clinical tool. Three sources of only ones [3]. information are essential to an evidence- based approach: a) an exhaustive Scientific advantages literature synthesis; b) meta-analysis; and c) consensus opinion. The Clinical practice guidelines incorporate systematic merging of evidence from the best available evidence for the these sources offers healthcare providers management of a disease or an aspect of a scientifically supportable document disease treatment or prevention into a that is flexible enough to deal with single document for health care clinically complex problems. Evidence- providers. The quality of practice based practice guidelines, in conjunction guidelines has improved by adopting with practice standards and practice standard approaches to the development advisories, are invaluable resources for of guidelines and reviewing their quality clinical decision making. The judicious for use in patient care. Implementing use of these documents by practitioners guidelines into clinical practice can will serve to improve the efficiency and improve quality and efficiency of care safety of health care well [5, 6]. and will likely benefit from a multidisciplinary, multifaceted approach The choice of guidelines [4]. Local healthcare providers may produce their own set of guidelines or adapt them from existing top-level guidelines.

88 During 1998 about 10000 per year. The payers, providers and advocates must number of clinical practice guidelines learn to appraise and interpret guideline included in Medline increased from one recommendations critically. to more than 450 per year in 1998.

The USA and other countries maintain Medical guidelines in UK medical guideline clearinghouses. In the USA, the National Guideline Guidelines are viewed as useful tools for Clearinghouse maintains a catalog of making care more consistent and high-quality guidelines published by efficient and for closing the gap between various organizations (mostly what clinicians do and what scientific professional physician) organizations). evidence supports. Interest in clinical In the United Kingdom, clinical practice guidelines is international and has its guidelines are published primarily by the origin in issues faced by most healthcare National Institute for Health and Clinical systems: rising healthcare costs; Excellence (NICE). In The Netherlands, variations in service delivery with the two bodies (CBO and NHG) publish presumption that at least some of this specialist and guidelines, variation stems from inappropriate care; respectively. In Germany, the German the intrinsic desire of healthcare Agency for Quality in Medicine (ÄZQ) professionals to offer, and patients to coordinates a national program for receive, the best care possible. Within disease management guidelines. All the UK, there is ongoing interest in the these organizations are now members of development of guidelines and a fast- the Guidelines International Network, an developing clinical-effectiveness agenda international not-for-profit association of within which guidelines figure organizations and individuals involved prominently. Over the last decade, the in clinical practice guidelines. G-I-N is methods of developing guidelines have owner of the International Guideline steadily improved, moving from solely Library - the largest web based data base consensus methods to methods that take of medical guidelines worldwide. explicit account of relevant evidence. However, UK guidelines have tended to Why top level guidelines focus on issues of effectiveness and have not explicitly considered broader issues, During the period 1975-1980 about 500 particularly cost [7]. new studies per year were added to Medline.The rate of publication of Perspectives clinical practice guidelines for common medical illnesses continues to accelerate. From September 2009, the Training and The appropriate dissemination and Development Center in the Iraqi uptake of high quality practice Ministry of Health will organize series guidelines can synthesize evidence, of symposia, lectures and training improve patient outcomes and enhance courses about the use of guidelines in the the efficiency of health care delivery. healthcare in Iraq. However, the methodological rigour and relevance of the growing number of publications labelled 'clinical practice guidelines' vary widely. Health care

89 References

1-Marshall JK. A critical approach to clinical practice guidelines. Can J Gastroenterol. 2000 Jun; 14(6):505-9. 2-Field MJ. In: Lohr KN, editor. Clinical Practice Guidelines: Directions for a New Program (Publication Iom, 90-08). Washington: National Academy Press; Oct 1, 1990. URL: http://www.nap.edu/books/0309043468/html/ind ex.html 3-Echevarría-Zuno S. [The clinical practice guidelines and health care efficiency.] Rev Med Inst Mex Seguro Soc. 2009 Jan-Feb; 47(1):1-3. 4-Wetterneck TB, Pak MH. Using clinical practice guidelines to improve patient care. WMJ. 2005 Apr; 104(3):30-3. 5-Connis RT, Nickinovich DG, Caplan RA, Arens JF. The development of evidence-based clinical practice guidelines. Integrating medical science and practice. Int J Technol Assess Health Care. 2000; 16(4):1003-12. 6-Lohr KN, Eleazer K, Mauskopf J. Health policy issues and applications for evidence-based medicine and clinical practice guidelines. Health 1998 Oct; 46(1):1-19. 6-Eccles M, Mason J. How to develop cost- conscious guidelines. Health Technol Assess. 2001; 5(16):1-69.

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