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Evidence-Based Clinical Practice
CLINICAL PRACTICE GUIDELINES UNIT
Hypertension in Pregnancy

Objectives:
To critically appraise a clinical practice guideline. This includes: 1. Understanding that not al published guidelines have the same quality, and that different guidelines may have a variety of recommendations. 2. Assessing the process the authors used to develop the guidelines.
3. Assessing the applicability of the guideline to your patient and your community.

Assignment:
1. Discuss the results of the paper on clinical guidelines by Thomson, et al (BMJ. 316:509- 2. Read the clinical scenario, and develop the clinical question. 3. Critically appraise two different clinical guidelines on the treatment of hypertension in
Enclosed Electronic Materials:
Document 1: This handout

Document 2: Thompson, et al. Guidelines on anticoagulant treatment in atrial fibrillation
in Great Britain: variation in content and implications for treatment. BMJ.1998:316;509-13.
Documents 3a and 3b: IOM’s “Clinical Practice Guidelines We Can Trust” documents
Available at:

Document 4: “Diagnosis, Evaluation, and management of the Hypertensive Disorders of Pregnancy”,
published by the Society of Obstetricians and Gynaecologists of Canada (2008). Note: For the purposes of this tutorial and to save paper when making hard copies, we have reduced the size of the file from 52 to 16 pages. The ful guideline is available for free at:
Document 5: “Hypertension in pregnancy: the management of hypertensive disorders during
pregnancy”, published by National Institute for Clinical Excellence (NICE), UK (2011) Note: For the purposes of this tutorial and to save paper when making hard copies, we have reduced the size of the file from 295 to 34 pages. The ful guideline is available for free at:
Document 6: Amerigroup Healthcare Group Guideline on Hypertension in Pregnancy.
2013 Longenecker
Background:
In 1998, BMJ published an article entitled, “Guidelines on anticoagulant treatment in atrial fibrillation in Great Britain: variation in content and implications for treatment” (“Document 2” in your reading materials). We will not critically appraise this article, but will review its findings briefly. It clearly illustrates one of the problems with Clinical Guidelines that you should understand.) The authors applied 20 separate clinical guidelines for anticoagulation in atrial fibrillation to 100 patients with atrial fibrillation. They reported that the percent of patients for whom anticoagulation was recommended by the guidelines ranged from 13% to 100% (see figure in the paper). This wide range in clinical advice, depending on the guideline, emphasizes the point that many guidelines may be developed non-systematical y, and may be based on opinion rather than evidence-based processes. Most of the guidelines in this study were not developed using evidence- based methods. It is therefore important to know how to identify, using critical appraisal, which guidelines correctly reflect the evidence base in the medical literature. The problem of differing levels of rigor in producing guidelines has led to efforts to standardize methods for guideline development. The GRADE working group is a group that has addressed this issue, with particular attention given to 1) how to assess the quality of clinical research evidence and 2) how to “grade” the strength of clinical practice recommendations. This effort also addresses the problem that clinicians face when each guideline or medical association creates their own grading system, such that “B” evidence in one guideline could refer to the same evidence as “3++” or “I -1a” in other guidelines. This tutorial reviews the components of critical appraisal for clinical guidelines.
Activity:
Review the IOM’s “Clinical Practice Guidelines We Can Trust” report and standards documents List the standards that should be met by Guideline Development Groups. 2013 Longenecker
Clinical Scenario:
A 36-year old female patient, whom you have followed for 3 years for obesity and hypertension, presents to you with the news that she is pregnant, currently at 3 weeks gestation. She wants to know if she should continue taking metoprolol for her hypertension, and what are the risks of adverse outcomes of this medication to her baby or herself. On physical examination, she is afebrile, with pulse 72, respiratory rate 14, and BP 142/89. Lungs are clear. Cardiac examination reveals a normal S1 and S2 and a I/VI systolic ejection murmur. There is Laboratory studies: Normal electrolytes, BUN, Cr.
PICO Questions:
1. 2. Search Strategy:
For clinical guidelines, an excellent resource to check first is the National Guideline Clearinghouse , a website that collects published guidelines that meet certain quality standards. • They also use the IOM guidelines (Documents 3a and 3b). You search the NGC for “Hypertension in Pregnancy”, and find the fol owing three guidelines: • “Diagnosis, Evaluation, and management of the Hypertensive Disorders of Pregnancy”, published by the Society of Obstetricians and Gynaecologists of Canada (2008) (Document 4)
• “Hypertension in pregnancy: the management of hypertensive disorders during pregnancy”, published by National Institute for Clinical Excellence (NICE), UK (2011) (Document 5)
• A more recent guideline (2012) by the American College of Gynecology is listed, but costs a fee to download it. You don’t have the funds to buy this one, so you decide to rely on the others you found (while wondering to yourself why they are charging for guidelines!? Of course, you then realize that it must take a massive effort to produce such documents.) A helpful friend of yours searches Google for you, and gives you a guideline on Hypertension in Pregnancy from the Amerigroup Healthcare group (Document 6).


Next Step: Critical Appraisal
You now are ready to critically appraise these three guidelines. Use the tables on the fol owing pages to outline your critical appraisal assessments for the three guidelines. Review the SOGC guideline first, then the NICE guideline, and finally, the one from Amerigroup. 2013 Longenecker
CRITICAL REVIEW FORM FOR CLINICAL PRACTICE GUIDELINES

Critical Appraisal Questions
SOG-Canada (2008)
NICE (2011 Update)
Amerigroup (2012)
A. Composition of Authors and Conflict of Interest
1.
Was the guideline developed by a clearly identified multidisciplinary group of
important stakeholder groups and experts (relevant physicians, nurses, and patients; and Did the guideline disclose potential conflicts of
Interest or bias for each member of the group
B. Is the guideline valid?
3.
What year was the guideline published?
Is it likely to include information on recent Are the methods used to produce the guideline clearly documented? Are they evidence-based
methods?
Did the authors search the literature with a
clear strategy for all relevant studies, and apply scientific rigor in synthesizing results? Are Do the guidelines present an evidence-based system for 1) assessing the quality of the
evidence, and 2) for grading the strength of
the recommendations? (i.e., adjusting strength
2013 Longenecker
Critical Appraisal Questions
SOG-Canada (2008)
NICE (2011 Update)
Amerigroup (2012)
Was the guideline subjected to outside review
clinical y-important statements?
Does each statement have a strength of
recommendation indicated? Are “major”
10. Is there a plan for updating this
C. If valid, do the results of this guideline apply to my patient?
11. Does the guideline clearly describe the target
apply? Can they be generalized to this patient?
12. Does the guideline clearly address my clinical
question?
13. Were al important outcomes considered?
14. Is there a consideration of cost-effectiveness?
15. Are the recommendations relevant to my local
situation? My patient’s situation (cost,

2013 Longenecker

Source: http://www.borhan.org.kw/website/pdf/Clinical%20Practice%20Guidelines%20Unit.pdf