Clinical Practice Guideline

Aka: Clinical Practice Guideline, Best Practices by Specialty, Choosing Wisely Campaign, Good Clinical Practice

1. Resources
   1. Clinical Practice Guidelines (NIH)
      1. https://www.nccih.nih.gov/health/providers/clinicalpractice
   2. National Guideline Clearinghouse (AHRQ)
      1. https://www.ahrq.gov/gam/index.html
   3. Institute of Medicine's Report Clinical Practice Guidelines We Can Trust (IOM)
      1. https://www.ncbi.nlm.nih.gov/books/NBK209538/
   4. Practice Guideline Articles (AAFP)
      1. https://www.aafp.org/afp/practguide
   5. Emergency Care Research Institute Guidelines Trust (ECRI)
      1. https://www.ecri.org/library/general-topics/
2. Precautions: Guideline Pitfalls
   1. Focused Interpretation
      1. Guideline development focuses on improvement of specific outcomes, with less focus on other related outcomes
      2. Guidelines should improve patient-oriented outcomes including harms versus benefits
   2. Speculation
      1. Expert opinion is inserted when evidence is lacking
      2. Guidelines should be based on systematic review of the research data, and graded with strength of evidence
   3. Extrapolation
      1. Recommendations are extrapolated beyond the original research focus
   4. Limited Representation
      1. Lack of stakeholder representation in the guideline development
      2. Key stakeholders (e.g. specialties, patients, payers, public health) should be involved in guideline development
   5. Oversimplification
      1. Guidelines may ignore nuances of confounding factors (disease severity, age, gender, comorbidity)
      2. Guidelines should apply to the patient population being treated
   6. Over-complication
      1. Guidelines are too complicated to reliably implement, with exceptions and numerous sub-pathways
      2. Recommendations should be clear and actionable
   7. Economically Unfeasible
      1. Costs of implementation (or the conflicts of interest by developers) may not be fully addressed
      2. Guideline development should not be industry sponsored and free of financial conflict of interest
   8. References
      1. Barry (2022) Am Fam Physician 105(4): 350-2 [PubMed]
3. Precautions: Emergency Medicine (Choosing Wisely)
   1. Minor Head Trauma imaging
      1. Avoid Head CT in minor Head Trauma when validated decision rules triage the patient to low risk
   2. Indwelling Urinary Catheters (Foley Catheters)
      1. Limit use to monitoring Urine Output in critically ill patients, urine obstruction, perioperative state and End-Of-Life Care
      2. Avoid indwelling Urinary Catheter in stable, voiding patients
         1. Not indicated for Urine Output monitoring in stable patients (void into measure container)
         2. Not indicated for convenience
   3. Palliative Care and Hospice
      1. Engage Palliative Care and Hospice early when indicated in chronic disease or End-Of-Life Care
   4. Skin Abscess management
      1. Avoid antibiotics and wound cultures for uncomplicated skin and Soft Tissue Abscesses
      2. Assumes definitive Incision and Drainage and appropriate follow-up
   5. Pediatric Dehydration Management
      1. Oral Rehydration Therapy should be the first-line intervetion in mild to moderate Pediatric Dehydration
      2. Intravenous replacement should be reserved for those who fail oral rehydration
   6. References
      1. http://www.choosingwisely.org/doctor-patient-lists/american-college-of-emergency-physicians/
4. Precautions: Family Medicine (Choosing Wisely)
   1. Low Back Pain imaging
      1. Avoid imaging in the first 6 weeks in uncomplicated Low Back Pain without red flags
   2. Acute Sinusitis antibiotic management
      1. Avoid antibiotics in mild to moderate Acute Sinusitis until >7 days of symptoms or symptom worsening after initial improvement
   3. Osteoporosis Screening with DEXA Scan
      1. Delay DEXA Scan until age 65 years in women, 70 years in men unless Osteoporosis Risk Factors dictate otherwise
   4. Cardiac screening in asymptomatic, low risk patients
      1. Avoid cardiac screening (Electrocardiogram, stress test) in asymptomatic, low risk patients
   5. Cervical Cancer Screening indications (Pap Smear and HPV screening)
      1. Avoid Pap Smear in women under age 21 years or following Hysterectomy for benign cause
      2. Avoid Pap Smear in women over age 65 years who had prior adequate prior screening and not high risk for Cervical Cancer
      3. Avoid HPV screening (with or without cytology) in women under age 30 years
   6. Labor Induction and Cesarean Section scheduling
      1. Avoid scheduled Labor Induction or C-Section prior to 39 weeks unless medically indicated
   7. Carotid Stenosis screening
      1. Avoid Carotid Artery Stenosis screening in asymptomatic patients
   8. Otitis Media antibiotics
      1. Observation is the preferred protocol in children ages 2-12 years with non-severe Otitis Media symptoms, and other observation criteria met
   9. Pediatric UTI imaging
      1. Avoid Voiding Cystourethrogram (VCUG) in children ages 2-24 months, with first febrile Urinary Tract Infection (UTI)
   10. Prostate Cancer Screening
       1. Avoid universal Prostate Cancer Screening with Prostate-specific Antigen (PSA) test or Digital Rectal Exam
       2. Prostate Cancer Screening when performed should be accompanied by Informed Consent of risks and benefits
   11. Scoliosis Screening
       1. Avoid screening asymptomatic teens for Idiopathic Scoliosis
   12. Oral Contraceptive Prescribing
       1. Blood Pressure measurements and medical history alone are sufficient to provide Oral Contraceptive prescriptions
       2. Avoid requiring pelvic exam or physical exam prior to writing for Oral Contraceptive medications
   13. References
       1. http://www.choosingwisely.org/doctor-patient-lists/american-academy-of-family-physicians/
5. Resources
   1. ABIM Choosing Wisely Site
      1. http://www.choosingwisely.org/doctor-patient-lists/