Keywords
1. GRADE Reporting
2. EAST Guidelines
3. Trauma Care
4. Clinical Practice Guidelines
5. Evidence-Based Medicine
The widespread adoption of evidence-based guidelines in healthcare has revolutionized the provision of quality medical care across various specialties. With the aim of standardizing patient care and improving outcomes, the Eastern Association for the Surgery of Trauma (EAST) has been at the forefront of incorporating the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach in the development of trauma care guidelines. A recent study, published in the Journal of Clinical Epidemiology, has undertaken a thorough examination of how EAST has integrated GRADE into their clinical practice guidelines (CPGs). This analysis, led by researchers from the University of Minnesota Medical School, not only highlights the progress made but also casts a spotlight on areas requiring further refinement.
The GRADE approach is designed to assess the quality of evidence and strength of healthcare recommendations. It emphasizes transparent and structured guideline development, considering patient values, preferences, and resource utilization—all of this, in addition to evaluating the balance between potential benefits and harms of a particular intervention or treatment. Given that trauma care is a fast-paced environment often dealing with life-threatening conditions, adherence to meticulously drafted guidelines is instrumental in delivering timely and effective treatment. The study published under DOI: 10.1016/j.jclinepi.2024.111260 scrutinizes the uptake and application of GRADE within EAST’s CPGs.
Researchers, led by Brett B. Norling and colleagues at the University of Minnesota and affiliated institutions, devised a methodological framework that included six predetermined criteria for the use of GRADE in CPGs. A diligent review of guidelines available on the EAST website identified 48 CPGs that referenced the utilization of the GRADE approach. The topics covered by these guidelines were wide-ranging, with trauma, and violence prevention accounting for the largest portion (23.9%). The team employed a systematic approach to appraise the guidelines, ensuring that all steps in the data abstraction process were executed independently and in duplicate for accuracy.
The study reveals that of the clinical questions addressed by these guidelines (using the PICO format – patient/population, intervention, comparison, and outcomes), a median of 3 were posed, encompassing a median of 2.5 critical outcomes. When it came to providing recommendations, more often a conditional/weak recommendation was made (51.4% of the time), while strong recommendations constituted almost a quarter (23.9%). Remarkably, for 15.9% of PICO questions (22 PICOs), no definite recommendations were put forth.
Nearly all the CPGs documented search dates and included a PRISMA flow diagram, demonstrating a robust protocol for literature review. Yet, when it came to delivering a comprehensive evidence profile or summary of findings, almost half of the PICO questions lacked this essential detail. However, the capability of the guidelines to determine the overall certainty of evidence has substantially improved over a period of analysis from 2014-2018 to 2019-2022.
Despite these advancements, the report pinpoints pivotal improvements East must consider going forward. One significant observation was that nearly half the PICO questions did not provide a complete evidence profile, which is central to the GRADE framework. The study also noted inconsistencies in reporting the evidence-to-decision-making process and justifying strong recommendations, particularly when based on evidence of low or very low certainty.
The study’s findings underscore that while EAST has made commendable strides in adopting GRADE to formulate many of its trauma-related guidelines, further enhancements are required. These enhancements include consistent provision of the overall certainty of evidence, reporting of the evidence-to-decision-making process, and justification for strong recommendations, especially those based on limited evidence.
Such an analysis is essential for the continued improvement of clinical practice guidelines, which serve as a compass for physicians navigating the complex landscape of trauma care. The ongoing assessment and fine-tuning of these guidelines ensure they evolve as dynamic documents, integrating the latest research while simultaneously embodying practical considerations of front-line trauma care.
As EAST and similar organizations continue to refine their guidelines, the ultimate beneficiary is the patient. With enhanced clarity and precision in guideline documentation, healthcare providers are better equipped to make informed decisions that align with the principles of high-quality, evidence-based medicine.
In conclusion, the study injects a heightened level of scrutiny into the development and reporting of CPGs, fostering an environment of continuous improvement and patient-centred care. The full study results, along with detailed recommendations for EAST, are available through the Journal of Clinical Epidemiology.
References
1. Norling, B. B., Miller, W. W., & Dahm, P. P. (2024). Uncovering Gaps in GRADE Reporting of Eastern Association for Surgeons of Trauma (EAST) Guidelines. Journal of Clinical Epidemiology, 10.1016/j.jclinepi.2024.111260.
2. Schünemann, H., Brożek, J., Guyatt, G., & Oxman, A. (2013). GRADE handbook for grading quality of evidence and strength of recommendations. Updated October 2013. The GRADE Working Group.
3. Balshem, H., Helfand, M., Schünemann, H. J., Oxman, A. D., Kunz, R., Brozek, J., … & Guyatt, G. (2011). GRADE guidelines: 3. Rating the quality of evidence. Journal of Clinical Epidemiology, 64(4), 401-406.
4. Guyatt, G. H., Oxman, A. D., Vist, G. E., Kunz, R., Falck-Ytter, Y., Alonso-Coello, P., … & Schünemann, H. J. (2008). GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ, 336(7650), 924-926.
5. Institute of Medicine (US) Committee on Standards for Developing Trustworthy Clinical Practice Guidelines. (2011). Clinical practice guidelines we can trust. Washington (DC): National Academies Press (US).