1. Clinical Practice Guideline Development Serving on Guideline Panels Peter Robertson, MPA Analyst, Research and Quality Improvement, American Academy of Otolaryngology-Head and Neck Surgery Barbara Warren National Coalition for LGBT Health

2. AAO-HNS Clinical Practice Guideline Development Process http://www.entnet.org

3. National Guideline Clearinghouse http:www.guidelines.gov Summary Usage Report 1/1/2010 - 12/31/2010 American Academy of Otolaryngology-Head and Neck Surgery Foundation Title Date Released to NGC # of Page Views Clinical Practice Guideline: Acute Otitis Externa 7/14/2006 11,907 Clinical Practice Guideline: Adult Sinusitis 8/22/2008 12,706 Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo 4/17/2009 10,572 Clinical Practice Guideline: Cerumen Impaction 4/17/2009 7,745 Clinical Practice Guideline: Hoarseness (dysphonia) 4/23/2010 7,042 49,972 A page view represents the first time a summary is viewed during a session

4. Impetus for Developing Guidelines Rising costs of healthcare Practice Variation $ $

6. The Guideline Development Process Institute of Medicine of the National Academies http://iom.edu/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust/Press-Release.aspx

7. Guidelines ARE NOT Review Articles! Guidelines contain key statements that are action-oriented prescriptions of specific behavior from a clinician Monitor Test Gather Interpret Perform Dispose Action Conclude Prescribe Educate Document Procedure Consult Advocate Prepare

8. Statement of Fact vs. Action Clinicians should not routinely administer or prescribe perioperative antibiotics to children undergoing tonsillectomy. Antibiotic therapy does not improve recovery after tonsillectomy The management of acute otitis externa should include an assessment of pain . The clinician should recommend analgesic treatment based on the severity of pain. Acute otitis externa (swimmer’s ear) is associated with moderate to severe pain. Observation without the use of antibiotics is an option for selected adults with uncomplicated acute bacterial sinusitis who have mild illness (mild pain and temperature <38.3 O C or 101 O F) and assurance of follow-up. Randomized controlled trials show that many episodes of uncomplicated acute bacterial sinusitis are self-limited. Clinicians should use pneumatic otoscopy as the primary diagnostic method for otitis media with effusion. Pneumatic otoscopy is the most accurate test for otitis media with effusion. Statement of Action Statement of Fact

11. Ranked Topic List for Sudden Hearing Loss Guideline

12. Two Approaches to Evidence and Guidelines Evidence as Protagonist Model Development is driven by the literature search, which takes center stage with exhaustive evidence tables or textual discussions that rank and summarize citations. Product is a Practice Parameter, Evidence Report, or Evidence-Based Review Evidence as Supporting Cast Model Development is driven by a priori considerations of quality improvement, using the literature search as one of many factors that are used to translate evidence into action. Product is a Guideline with Actionable Statements

16. Forbes Magazine – November 30, 2009

17. Action Palate for Guideline Recommendations Never use the word CONSIDER to describe an action! Essaihi et al, AMIA Ann Symp Proc 2003; 220-4 Test Obtain or collect additional data Prescribe Order a treatment requiring medication or durable equipment Perform Perform therapeutic procedure; order therapeutic activities Educate/counsel Inform patient about means to improve/maintain health Dispose Initiate an activity to direct patient flow (admit, transfer, etc.) Monitor Make serial observations according to specific criteria, schedule Refer/consult Direct a patient to another clinician for evaluation or treatment Prepare Make ready for a guideline-related activity by training, etc. Document Record one or more facts in the patient record Advocate Argue in support of a policy Diagnose Determine a diagnose or clinical status

18. Developing Key Action Statements

22. Classifying Recommendations for Practice Guidelines AAP Steering Committee on Quality Improvement and Management Pediatrics 2004; 114:874-877

23. Action Statements as Behavior Constraints Be flexible in decision making regarding appropriate practice, although bounds may be set on alternatives Generally follow a recommendation, but remain alert to new information Follow unless a clear and compelling rationale for alternative approach exists Implication for clinicians Option Recommendation Strong recommendation Policy strength Cross-sectional survey of 1,332 registrants of the 2008 annual AHRQ conference given a clinical scenario with recommendations and asked to rate the level of obligation they believe the authors intended Lomotan E, et al. How “should” we write guideline recommendations? Interpretation of deontic terminology. Quality Safety Health Care 2009; In press.

26. Pediatrics 2004; 114:874-877 Classifying Recommendations for Practice Guidelines AAP Steering Committee on Quality Improvement and Management

29. Is the Guideline Actionable? Guideline Implementability Appraisal (GLIA) Yale Center for Medical Informatics BMC Med Informatics Decis Making 2005; 5:23-31