American Psychiatric Association Practice Guideline Development

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American Psychiatric Association Practice
Guideline Development

• Challenges and Ideas for Standards

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Laura J. Fochtmann, M.D.

• Professor, Departments of Psychiatry and
  Behavioral Science and Pharmacological Sciences,
  Stony Brook University, Stony Brook, New York
• Medical Editor, Practice Guidelines, American
  Psychiatric Association
• No disclosures

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APA Practice Guidelines

• Acute Stress Disorder and PTSD (2004)
• Alzheimers Disease and Other Dementias (1997,
  2007)
• Bipolar Disorder (1994, 2002, in development)
• Borderline Personality Disorder (2001)
• Delirium (1999)
• Eating Disorders (1993, 2000, 2006)
• HIV/AIDS (2000)
• Major Depressive Disorder (1993, 2000, in
  development)
• Obsessive-Compulsive Disorder (2007)
• Panic Disorder (1998, 2009)
• Psychiatric Evaluation (1995, 2006)
• Schizophrenia (1997, 2004)
• Substance Use Disorders (1995, 2006)
• Suicidal Behaviors (2003)

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Print publications
Concise formats
Online
Quality indicators
Self-Evaluation Tools
Education and Certification
Examinations
National Guideline Clearinghouse
CME
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APA Development Process

• Comprehensive literature search
• Evidence tables
• Expert work group
• Zero industry funding
• Conflict of interest policy for all participants
• Broad, iterative review of drafts
• Approval by the APA Assembly and Board of Trustees

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General Development Challenges

• Increasing demand for new guidelines
• Need for constant updating of prior guidelines
• Volume of new evidence
• Time- and resource-intensive development process,
  especially for rigorous systematic literature
  reviews
• Composition of volunteer work groups
• Approval through APA governance

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Funding Challenges

• Need to maintain independence from industry
  funding
• Desire for broad dissemination over publication
  profits
• Limited funds available for staff and other
  support
• Limited public grant opportunities to support
  development?

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Challenges Related to Available Evidence Base

• RCTs may be unavailable for important clinical
  questions or for off-patent treatments.
• RCTs can be biased.
• Studies often have limited generalizability.
• Available data rarely lend themselves to medical
  decision analysis.
• Relatively small samples do not permit assessment
  of confounds or special factors that may alter
  treatment.

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Challenges in Determining Strength of
Recommendation

• Evidence is rarely straightforward to translate
  into practice recommendations.
• Best methods for achieving consensus
  recommendations have not been defined (e.g.,
  methodology, consensus panel composition,
  strength ratings).
• Consensus of a small expert panel may not
  represent broader clinical opinion.

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Challenges in Increasing Usability and Adherence

• Need for broadly stated recommendations to
• Reflect complexity of real world patients
• Give clinicians flexibility in individualizing
  care without creating medicolegal or utilization
  review difficulties
• Reflect ambiguous or limited evidence
• Need for simplification and clarity to
• Enhance use of guidelines at the point of care
• Make them applicable to specific clinical
  situations
• Translate them into quality measures and
  machine-readable algorithms

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Ideas for Standards for Guideline Development

• Specify clear, distinct criteria for strength of
  evidence and ratings of recommendation strength
• Be explicit about evidence used in making a
  recommendation, method by which the
  recommendation was reached, and evidence gaps.
• Develop standardized approaches to considering
  (and making explicit or minimizing) effects of
  bias.
• Develop standardized methods for achieving
  consensus.
• Allow for flexibility in composition of guideline
  panels.
• Choose clinically meaningful EHR and quality
  measures.
• Recognize that guideline-related needs of
  clinicians and patients may vary across
  specialties and settings.

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Ideas for Improving Guideline Concordance and
Currency

• Standardize the reporting of clinical trial data.
• Create a publicly funded database of the clinical
  trial evidence tables (e.g., within MEDLINE).
• Create a mechanism for developers to share
  information about guidelines that are in process.
• Continue expansion of AHRQ funding of systematic
  reviews.
• Consider alternative models for funding of
  guideline development per se
• Avoid standards or accreditation that would place
  additional costs or burdens on guideline
  development by professional societies.

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APA Steering Committee on Practice Guidelines

• Joel Yager, M.D., Chair
• James E. Nininger, M.D., Vice-Chair

• Daniel J. Anzia, M.D. Sherwyn M. Woods, M.D.,
  Ph.D.
• Thomas J. Craig, M.D. John S. McIntyre, M.D.,
  Consultant
• Molly T. Finnerty, M.D. Kristen Ochoa, M.D.,
  Fellow
• Francis G. Lu, M.D. Jeremy Wilkinson, M.D.,
  Fellow
• Paul Summergrad, M.D. Sheila Hafter Gray, M.D.,
  Liaison
• Michael J. Vergare, M.D.

APA Staff
Darrel A. Regier, M.D., Director, Division of
Research Robert M. Plovnick, M.D., M.S.,
Director, Dept of Quality Improvement Robert
Kunkle, M.A., Director, Practice Guidelines
Project