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Development of the AHCPR-sponsored heart failure guideline: methodologic and procedural issues
Insights
Developing clinical practice guidelines for heart failure management involved a complex consensus process. Frequent expert input and peer review ensured broad clinical acceptance of the final recommendations.
Area of Science:
- Health Services Research
- Clinical Practice Guidelines
- Cardiology
Background:
- RAND Corporation contracted for the Agency for Health Care Policy and Research (AHCPR)-sponsored guideline.
- Guideline focused on managing heart failure due to left-ventricular systolic dysfunction.
Purpose of the Study:
- To outline the complex process of developing clinical practice guidelines.
- To detail methods for achieving consensus on practice recommendations.
Main Methods:
- A 16-member panel engaged in discussions to reach consensus on practice recommendations.
- A draft algorithm served as a central tool, iteratively revised throughout the process.
- National experts were consulted early and frequently to address controversial issues.
Main Results:
- Key decisions involved focusing the guideline, rating evidence strength, and linking evidence to recommendations.
- Consensus was achieved even in the absence of data or with differing opinions.
- The process facilitated conclusions on complex issues like coronary artery revascularization evaluation.
Conclusions:
- The guideline development was a complex and painstaking process.
- Frequent peer review and expert consultation contributed to a widely acceptable guideline.
- The developed guideline is expected to achieve broad clinical and geographic acceptance.
Background:
RAND, a nonprofit research and policy organization, served as contractor for the Agency for Health Care Policy and Research (AHCPR)-sponsored guideline on the management of patients with heart failure due to left-ventricular systolic dysfunction.
Panel:
At meetings of the 16-member panel, discussions concerning practice recommendations were held until a consensus was reached. A draft algorithm was the key tool, serving as a starting point for panel discussion. The algorithm was revised after almost every panel meeting.
Key Methods And Procedural Issues:
Early decisions included how best to (1) focus the guideline and literature review, (2) rate the strength of evidence underlying practice recommendations, and (3) determine the relationship between strength of evidence and strength of recommendation. In the absence of data, or when panelists did not share a common opinion, the panel attempted to achieve a consensus. An example of this process--when and how patients should be evaluated for possible coronary artery revascularization--is discussed at length. Unlike previous AHCPR guideline panels, this panel solicited opinions of national experts early and often during guideline development. This process helped the panelists arrive at conclusions on certain controversial issues.
Conclusions:
The guideline development process was complex and painstaking. The panelists and project staff believe that frequent peer review helped produce a guideline that can be widely accepted across clinical and geographic lines.