Toward evidence-based approach to deep venous thrombosis.

When approaching patients with a suspected medical condition, such as deep venous thrombosis (DVT), physicians often are faced with considerable uncertainty. Such approach should-in principle-be guided by the published literature, but this may not be a simple task. For a majority of practicing physicians, it is not only difficult to keep up with the rapidly proliferating number of published studies, but it is also a challenge to make in-depth interpretations of the often-conflicting findings. In addition, physicians usually incorporate their knowledge, experience, local practices, and patient preferences in the process of decision-making. It is not surprising, therefore, to have considerable variation in practices related to DVT, even among experts in the field.[123] Variation has been documented across the whole spectrum of DVT management, including surveillance of asymptomatic patients, diagnosis, pharmacological prophylaxis, mechanical prophylaxis, treatment of DVT, and work-up for hypercoagulability.[1] One must note that not all variation is unwarranted; some patient-centered variation may actually be desirable. Unwarranted variation reflects failure in application of professional knowledge.[4] Because it is associated with worse outcome and increased cost, reducing unwarranted variation has been a major target for quality improvement initiatives.[4]

Clinical practice guidelines (CPGs) are an important tool to reduce unwarranted variation by standardizing practice. CPGs have the potential to improve clinical practice and patient outcome, to enhance translation of research into practice, and to improve quality and safety of care.[5] CPGs also guide the development of performance measures, which are a cornerstone in quality improvement projects and can be used to provide objective information on the quality of healthcare providers and institutions.[5] Recognizing the need for CPGs for DVT, several countries and professional societies have produced CPGs that address different aspects of its management.[678]

In this issue of the Annals of Thoracic Medicine, Dr Alhameed and colleagues published “The Saudi CPG for the Diagnosis of the First Deep Venous Thrombosis of the Lower Extremity”.[9] This was a part of a large initiative by the Saudi Arabian Ministry of Health to establish CPGs with the goal of improving care in the Kingdom by standardization and reducing unwarranted variation. The Saudi expert panel from the Saudi Association for Venous Thrombo-Embolism (SAVTE), a subsidiary of the Saudi Thoracic Society generated this CPG in collaboration with the McMaster University Working Group for Clinical Practice Guidelines. In the current CPG, the panel addressed 24 questions selected using a formal prioritization process.

Because of the implications of CPGs, the quality of CPGs has recently become an area of public focus. Upon a request from the US congress, the Institute of Medicine (IOM) developed a set of eight standards for rigorous, trustworthy CPGs.[5] These standards were based on the literature, expert consensus, and public input. All CPGs should meet all eight standards. The first standard is transparency; by having the processes of development and funding detailed and publicly available. The authors of the current CPG have already made this information available by publically publishing their methods.[10] The second standard, which is management of conflict of interest, implies that the CPG development group optimally comprises members who have no conflict of interest (COI). If this is not possible, the individuals with COI should represent only a minority of the group. In addition, the COI should be clearly disclosed. The authors have provided a statement on COI. The third standard is related to the CPG group composition, which should be multidisciplinary and balanced, comprising methodological panel of experts and clinicians. In addition, patient and public involvement should be incorporated in the process. The composition of the Saudi expert panel reflects a multidisciplinary group of clinicians with methodological experts from the McMaster University Working Group. Patient values and preferences are included in the CPG, although direct patient and public involvement would have an added value. The fourth standard is related to the CPG — systematic review intersection. CPG should be based on systematic reviews that meet standards set by the Institute of Medicine for Systematic Reviews.[11] The Saudi expert panel has used updated systematic reviews in reaching their findings. The fifth standard is establishing evidence foundations for rating strength of recommendations. In the current CPG, the authors provided a summary of relevant available evidence with a description of the quality, they described the resource use and applicability, they provided insight to patient values and preferences, and provided implementation considerations. For each question, they provided a rating of the quality of evidence according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system[12] as well as a rating of the strength of the recommendation in light of the preceding data. The sixth standard is the articulation of recommendations in a standardized form detailing the recommended action and circumstances under which it should be performed. This was evident in this CPG. The seventh standard is related to having a process of external review that includes relevant stakeholders, including scientific and clinical experts, organizations and agencies, patients, and representatives of the public. External review should be considered in updated versions of this CPG. The eighth standard relates to updating the CPG. The CPG document should indicate the date of systematic evidence review, and proposed date for future CPG review. In the current CPG, the Saudi expert panel included updated systematic reviews and suggested periodic updates of this guideline every 2-3 years.

The Saudi expert panel is to be congratulated on this important professional work. This is a step toward evidence-based approach to deep venous thrombosis in Saudi Arabia.