Abstract
Junior perspective
Good clinical guidelines help us put our knowledge into practice, and ensure that we are keeping in line with best practice and evidence-based medicine. As a trainee gastroenterologist, guidelines are going to be a hugely important resource to base your approach to patients in all aspects of care, from investigation and diagnosis to management and treatment options. One of the main objectives of a guideline is to provide information and advice to ensure that the management of a specific condition is standardised and carried out in an evidence-based approach, which has been assessed and developed based on the robust experience of experts in each area and scientific evidence from clinical studies.
Thanks to UEG, finding these guidelines is no longer a problem; as the Standards and Guidelines taskforce have developed an online repository of currently available European guidelines. At present, 251 guidelines across all areas of gastrointestinal health are available and freely accessible to everyone on the UEG website at https://www.ueg.eu/guidelines. In addition, the Standards and Guidelines taskforce is currently working on increasing the scope of the repository by encouraging and facilitating the development of guidelines not currently available as identified by our gap analysis. UEG is trying to stimulate the development of new guidelines from its member societies by awarding UEG activity grants. Guidelines can also be found on the websites of most specialist member society websites according to their area of specialist interest, including ECCO, EASL, ESPEN and ESGE. The UEG guideline repository provides links to the guidelines of the respective member societies.
However, it is important for trainees to understand that different forms of guidelines exist, and that not all should be considered equal. Prior to including new guidelines in the UEG repository, the taskforce members perform a vigorous review of the article to ensure that the design and methodology is of a high level, and that the consensus members or authors represent the experts in the specific field being reported on. Furthermore, we ensure that the development of the guideline was not sponsored in any form by the pharmaceutical industry, as this would have implications for bias and may limit the integrity of the guideline. Finally, there are a number of different types of guidelines available, and even those with expert authors and reliable evidence-grading systems need to be interpreted with a certain amount of caution. It is important to retain and use your own clinical judgement, and develop the ability to adapt these guidelines to fit into your own clinical practice based on local expertise and resources. Generally, we classify guidelines according to the level of evidence that they are based on into five categories, with the strongest level of evidence being a clinical practice guideline. This is the strongest form and is based on a systematic review of the literature and the development of specific recommendations that are agreed upon and graded by a group of experts, according to a robust assessment using either the Delphi technique or an equivalent approach. Other types of guidelines include clinical standards, consensus reports, position papers and standard protocols. Generally, the strength of a guideline, determined by the methodology used, is dictated by the amount of published data and available evidence resources. So, particularly for newer or rarer conditions, only weaker forms of guidelines may be currently available and it is important to be able to identify differences. Bearing in mind that each type of guideline may be useful in clinical practice, it is just important to be aware of the differences in methodology so that you can appraise the information and apply it to your practice in an informed manner.
Once you have found an interesting or useful guideline, the next step is to develop an approach to reading it. This may be decided by the amount of time you have available, and the urgency for which you need guidance, as published guidelines are generally very comprehensive and therefore can be very long. They generally provide a broad overview of a condition, often starting with a background on aetiology and epidemiology, moving onto clinical presentation, diagnostic workup and the short- and long-term management, so they can be a valuable learning resource if you have time to read them in full. In the clinical setting on the other hand, you often need information and guidance on the spot to look after a patient in front of you, so you will need to be able to scroll quickly through or search the guideline to answer a specific question. For this type of scenario a summary, scoring system or algorithm-based tool may be more useful and several of the specialist societies and expert groups have developed apps that can be downloaded to mobile devices for more urgent help.
Senior perspective
One of the major goals of UEG is the advancement of care in digestive health by improving the prevention and management of digestive diseases in Europe. Providing easy access to clinical standards and guidelines of high quality for the prevention and management of digestive disorders for all European health care professionals will hopefully ultimately result in a reduction of health inequalities across Europe and provide state-of the art care all over Europe.
Generally, clinical practice guidelines are defined as ‘systematically developed statements to assist health care professional and patient decisions about appropriate health care for specific medical problems’. Guidelines are usually utilised for several purposes:
To assist clinician decision making To educate individuals or groups To assess and assure quality of care To guide allocation of resources To reduce the risk of legal liability for negligent care
However, benefits of clinical standards and guidelines are only as good as the underlying quality of evidence that is used to develop the recommendations. As medicine is rapidly changing and new concepts are evolving, it is extremely important that guidelines are frequently updated and are based on information of strong evidence, as poor guidelines may be more harmful than helpful. Unfortunately, not all available clinical standards and guidelines frequently base their recommendations on high quality evidence, but are based on lower quality evidence or expert opinion. Sometimes guidelines are also not updated early enough to keep track with medical progress.
Key components to assess the usefulness and relevance of a clinical standard or guideline should include the following: the decision-making process (e.g. diagnosis and management), potential risks, review of relevant evidence, costs and presenting the information in a concise and easy-to-read format.
To standardise the development of guidelines, multiple papers and society statements have been published providing guiding principles for the development of clinical guidelines. However, the process of this standardisation varies greatly by society and by country. Therefore, the AGREE (Appraisal of Guidelines for Research & Evaluation) statement was formulated as an international endeavour (AGREE: Available at: http://www.agreetrust.org/) in order to improve the overall quality of practice guidelines. The quality of clinical guidelines may be also limited by potential conflicts of interest (COI). Particularly for guidelines, in which recommendations are based on expert opinion or lower quality evidence, the presence of COI may result in bias. Potential COI also may impact on the perception of the guidelines. A recent survey published in the New England Journal of Medicine noted that physicians were concerned about potential bias, when studies were sponsored by pharmaceutical companies and therefore were less likely to believe the findings of the trials. Therefore a good clinical standard or guideline should include statements on potential conflicts of interest of the participating panellists in order to help the readers to judge about potential conflicts of interest. UEG decided to exclude from its repository all guidelines of standards and guidelines that have been supported or in which industry has been directly involved. As clinical guidelines are increasingly published by both national and international organisations, multiple guidelines often are written on the same topics. In general, the development of duplicated guidelines does not seem to be appropriate, as it may result in waste of resources. The World Health Organisation (WHO) stipulates that if strong quality guidelines exist for the same topic by a recognised national leader, then duplicating this work is not appropriate. However, cascading guidelines to the national needs of a local country and the availability of medical service may be sometimes appropriate to allow for the best care according to availability of educational, technical and financial resources.
In order to facilitate the use of clinical standards and guidelines throughout Europe, UEG has developed a repository of standards and guidelines that is freely accessible to everyone on the UEG website at https://www.ueg.eu/quality-of-care/guidelines. The major aims of UEG are to increase the use and also the scope of the repository by optimising the technical use of the repository and filling gaps in areas of missing and/ or incomplete guidelines. In addition, UEG is encouraging strategies to facilitate the implementation and evaluation of guidelines with the help of UEG activity grants.
All guidelines in the UEG repository are publicly available and searchable alongside other educational material in the UEG education library using an easy search tool, making all guidelines of this repository easy to find. The use of the guidelines repository may be very useful for all health care professionals that are either specialised to a specific area of GI diseases and also for those who have to cover a broad spectrum of GI related diseases, even as general practitioner. Specialised health care professionals may be more familiar with guidelines related to their area of interest and the producing special member societies, while health care professionals that are not that specialised may sometimes not be even aware of specific disease related guidelines or societies specialised on specific diseases. The latter group may benefit from getting quick state of the art information by using the UEG guideline repository. The experience and expertise of UEG’s members in the development of standards and guidelines, and their willingness to have their guidelines collected in a central web-based repository, is thus greatly valued. With the current standards and guidelines repository, individual researchers, health care professionals and patients have convenient access to clinical standards and guidelines that cover the full breadth of digestive diseases. These clinical practice guidelines will reach now a greater audience and receive hopefully greater use and visibility that will in the end help to facilitate the harmonisation of standards of care and reduce health inequalities across Europe. We hope you will explore the clinical standards and guidelines material available at your fingertips by visiting https://www.ueg.eu/quality-of-care/guidelines.