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Sifting Through and Taking Guidelines with a Grain of Salt
At the recent International Liver Congress, the European Association for the Study of the Liver released five different guidelines for the management of liver disease. I encourage you to read our summaries, briefly here and more in-depth online, and consider how these may help you in your daily practice.
If you compare these guidelines to those recently released by AASLD, ACG and AGA, you will notice a difference in presentation.
European vs. American
The European guidelines tend to follow a more traditional format, in that they present an overview of the disease state in addition to discussing management decisions. Some of the recently released American guidelines are less comprehensive as a review. It is also important to consider the publication date. The recently released European guidelines may be more current compared to their American counterparts.
The European guidelines may tell a better story, walking you through the disease state, prevalence, incidence and diagnostics more so than our American guidelines. And this may teach more about the disease itself, but, at times, it is harder to find the specific answer for your specific question.
Our societies — AASLD, ACG and AGA — moved toward the question-and-answer format in line with Quality Assurance Practice Improvement movement put forward by CMS. The hope is that these may better help practitioners find questions fitting their particular situations and hear from the experts about how that could be managed, assuring quality and improvement.
Still other guidelines are joint efforts between societies, such as the hepatic encephalopathy guidelines produced by AASLD and EASL. One of the most widely consulted joint-guidance documents is the AASLD/IDSA HCV Guidance: Recommendations for Testing, Managing, and Treating Hepatitis C (http://www.hcvguidelines.org). Rather than relying on a stagnant paper version, this document is continually updated as new and impactful information becomes available. Thus, they are designed to be accessed in real-time online.
A clinician is best served by consulting relevant information. The most current guideline is likely to have incorporated impactful drug and clinical development. If you understand there are caveats in practice pattern — institutionally or due to drug availability — the European guidelines can augment your practice. All our societies produce guidelines and physicians should be aware of the most recent guidelines no matter the producer. Each physician must sift through these various sources to find what works best for him or her and the patient in question.
Quality of Evidence
Additionally, I encourage all of you to look at the quality of evidence in these guidelines and consider your own knowledge and opinions when addressing your patients. Nearly all the societies use grades to rank the quality of the evidence, but when you look through the guidelines, many are very low quality recommendations. We just don’t have the data to make more firm recommendations.
When you look at AGA’s guidelines for hepatitis B reactivation, for example, much relies on expert opinion. These experts will tell you what the evidence supports, but when you’re trying to decide your own practice management path or how to manage the person in front of you, it helps to read the statement and then look at the level of evidence. If it’s all expert opinion and you do not agree with it, it’s easier to rationalize another route, but if it’s all evidence-based and that evidence is high-quality, perhaps your opinion needs modification.
Remember that guidelines are truly guidance. They are not meant to be dogma. They are an outline of combined data and expert opinion and should be used with a grain of salt. They may not answer the question your patient has or your patient may not respond the way the guidelines suggest. They are a starting point to help you process the data, but not be the end-all, be-all for your personal practice choices.