Recommendations for the diagnosis and management of osteoporosis.

To the Editor: I read with interest the recommendations for the diagnosis and management of osteoporosis by Hussein Raef et al published in the July/August 2004 issue. I have several concerns about the methodology used in the synthesis of these recommendations. First, the authors did not provide any systematic method for searching the literature, which makes these recommendations prone to bias in the selection of included studies. In addition, the authors did not provide any description of included and excluded studies. Second, there is no linkage of the recommendations to their level of evidence. This issue is a key feature of high quality Clinical Practice Guidelines (CPGs), as recommendations that are based on expert opinion are not as valid as recommendations based on level 1 evidence.1 It has been shown that when health care providers accept and follow CPGs, they have the potential to improve both the process of care and patient health outcomes.2,3 However, concerns about the quality of guidelines might limit their acceptance and application by health care providers.4 The cost and resources needed for the development of CPGs is huge and few practices have the resources and skills to develop valid high quality guidelines.5 The overall cost can be considerably reduced if guideline developers “locally adapt” high quality guidelines as a basis for producing their own guideline. There is a growing recognition that national guideline developers do not need to duplicate efforts and waste resources in the development of CPGs. Several developed countries (e.g., New Zealand, Germany and Iceland) encourage local adaptation of international good quality guidelines to avoid duplication of work and cost involved in guidelines development. Local adaptation of CPGs addresses local clinical issues and circumstances and gives a sense of ownership of the clinical guidelines. The Guideline International Network (GIN) suggested a comprehensive methodology for the local adaptation of clinical guidelines.6 There are several high quality osteoporosis guidelines that follow high methodological standards available in the literature.7,8 If the authors tried to “locally adapt” these high quality guidelines they would save significant time and resources, and they would produce a much more useful guidelines for practitioners in Saudi Arabia. This is not limited to osteoporosis guidelines; wherever possible, all Saudi guideline developers should work on the local adaptation of existing good quality guidelines.