Christine Laine, MD, MPH, Editor in Chief; Darren B. Taichman, MD, PhD, Executive Deputy Editor; Cynthia Mulrow, MD, MSc, Senior Deputy Editor
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University of Ghent, General Practice
July 5, 2011
Cultural Differences in Clinical Guidelines
Dear editor, The editorial of June 7th about trustworthy clinical guidelines rightly mentions possible concerns about guidelines but other important concerns may remain and may relate to (cultural?) differences in interpretation of the available studies.
In an international comparison of acute sore throat guidelines for example (1), six national guidelines recommend diagnostic testing and prescribing antibiotics to prevent acute rheumatic fever if a streptococcal pharyngitis is suspected, whereas four other national guidelines discourage diagnostic testing and reserve antibiotics for high- risk patients only. Hereby, each guideline may -according to the interpretation and selection of the evidence and to the IOM criteria - pretend a sufficient level of evidence and strength of recommendation.
How to unravel this tangle and trust clinical guidelines?
Guidelines deserve a bibliographic analysis with a cited evidence score, for example with number of cited intervention studies (meta- analyses) in a single guideline) / maximum possible number of unique intervention studies (meta-analyses) cited according to the publication date of the guideline (2). Evidence citation scores will allow a better assessment and comparison of guidelines and will untangle for example cultural differences (3).
Another point of discussion is how to deal with the proposal of authors to expand guideline recommendations in specific conditions, in an era in which evidence is lacking (4, 5).
1. Matthys J, De Meyere M, van Driel ML, De Sutter A. Differences among international pharyngitis guidelines: not just academic. Ann Fam Med. 2007;5:436-43.
2. Van de Velde S, Heselmans A, Donceel P, Vandekerckhove P, Ramaekers D, Aertgeerts B. Rigour of development does not AGREE with recommendations in practice guidelines on the use of ice for acute ankle sprains. BMJ Qual Saf 2011;bmjqs.2010.045435.
3.Christiaens T, De Backer D, Burgers J, Baerheim A. . Guidelines, evidence, and cultural factors. Scand J Prim Health Care. 2004;22:141-5.
4. Centor RM. Expand the pharyngitis paradigm for adolescents and young adults. Ann Intern Med. 2009;151:812-5.
5. De Meyere M, Matthys J. Should we expand the pharyngitis paradigm for adolescents and young adults? Ann Intern Med. 2010;152:477-8.
Laine C, Taichman DB, Mulrow C. Trustworthy Clinical Guidelines. Ann Intern Med. 2011;154:774–775. doi: 10.7326/0003-4819-154-11-201106070-00011
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Published: Ann Intern Med. 2011;154(11):774-775.
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