It’s an oft-repeated phrase: Two heads are better than one. Likewise, the AAFP has found that when developing clinical practice guidelines, 2 organizations are often better than one. In fact, of the last 9 AAFP clinical practice guidelines, 8 involved other organizations. What does this trend toward collaboration mean?
“We’re leaders,” states AAFP Scientific Activities Division Director Herbert Young, MD. “Other organizations recognize this and want to work with us.”
While bringing organizations together results in a larger team and thus a lengthier approval process, says Young, the benefits abound. According to Young, collaborating on guidelines serves 2 purposes. First, it brings together 2 or more organizations, each having a perspective specific to its membership. Second, the collaboration usually guarantees more impact and wider dissemination than would occur if just 1 organization worked on a guideline.
“The Academy is making a conscious effort not to have guidelines that duplicate those of other organizations,” says Richard Clover, MD, of Louisville, Ky, chair of the Commission on Clinical Policies and Research. “It’s more efficient to work together.” If 2 organizations developed separate guidelines on the same topic, confusion could ensue, Clover said.
“Management of Newly Detected Atrial Fibrillation,” the result of work by the Joint Panel of the AAFP and the American College of Physicians on Atrial Fibrillation, premiered in the December 16, 2003, Annals of Internal Medicine, reaching 115,000 internists and medical students. News of the guidelines also appeared in AAFP communications vehicles, reaching its 93,700 members.
The joint panel reviewed almost 200 studies to devise its recommendations and determined that the literature did not support the conventional treatment to try to achieve sinus rhythm in patients with newly detected atrial fibrillation, says panel Co-chair Michael LeFevre, MD, a professor of family medicine at the University of Missouri–Columbia School of Medicine. “This guideline asserts that the best approach for most patients with atrial fibrillation is to focus on control of heart rate and stroke prevention, rather than attempt to restore sinus rhythm.”
ACP and AAFP first collaborated as partners in the Headache Consortium, which comprised more than 20 medical societies. AAFP and ACP worked further to develop the Headache Consortium guidelines into a set that focused more on primary care. That set was published in the November 19, 2002, Annals of Internal Medicine. Two more clinical practice guidelines—on deep venous thrombosis and pulmonary embolism—are in the works between the 2 organizations.
PICKING A PARTNER
Young maintains that the AAFP was one of the first organizations to embrace evidence-based medicine, and early on had to walk away from collaborations in which other partners did not embrace the methodology.
The Academy has found it easiest to work with other primary care organizations such as ACP and the American Academy of Pediatrics, Young says, but AAFP has also worked with subspecialty organizations such as American Academy of Neurology and American College of Cardiology.
The decision by the AAFP to collaborate on a clinical practice guideline rests on 2 factors, says Young: the methodology and the relevance to family medicine.
For some guidelines, the AAFP goes it alone. The updating of AAFP policy on vaginal birth after cesarean section is one such example. The American College of Obstetricians and Gynecologists declined to participate.
LEVEL OF INVOLVEMENT
The Academy participates with other organizations on a number of levels.
Level 1 involvement requires a major investment of resources in development of the clinical practice guidelines. This level of involvement usually entails having several AAFP representatives participate in the panel with an equal number of members from other organizations. The atrial fibrillation guidelines are the product of level 1 involvement. Another level 1 endeavor, an AAFP collaboration with the American Academy of Pediatrics to develop guidelines on otitis media and otitis media with effusion, due to be released this year, will address the issue of watchful waiting and antibiotic use.
Level 2 involvement typically involves sending an AAFP liaison to participate as panel members on discussions of clinical practice guidelines. At the end of the process, the Academy can endorse the guidelines if it meets AAFP criteria. Such an arrangement led to AAFP endorsing the American Academy of Pediatrics clinical practice guideline, “Treatment of the School-Aged Child With Attention-Deficit/Hyperactivity Disorder,” published in the October 2001 Pediatrics.
Level 3 participation entails less involvement. It comes about when other organizations want a family medicine perspective as part of their guideline development, and the Academy will suggest family physicians—not official AAFP representatives—to participate.
Furthermore, the AAFP reviews draft guidelines from other organizations as part of their peer-review process.
SELECTING A TOPIC
The AAFP Commission on Clinical Policies and Research jump-starts the Academy’s work on a clinical guideline topic by seeking approval from the AAFP Board of Directors. The commission has funding to work on 3 guidelines at any 1 time.
When nominating topics for guideline development, the Academy asks the Agency for Healthcare Research and Quality to develop an evidence report. AHRQ has criteria for topics: They must be common and there must be a “significant burden of suffering” associated with the condition. If the government chooses to fund the evidence report, the topic goes to an evidence-based practice center for development of an evidence report on the topic. The guidelines panel often builds its recommendations from the evidence report.
The involvement of primary care in nominating topics is important, says Young, particularly where comorbidities are concerned. Subspecialists tend to focus on a condition in isolation, even though it is the norm for many conditions to occur in tandem (for instance, myocardial infarction and depression).
The bottom line: The Academy takes steps to make clinical guidelines reflect the patient-centered orientation of family medicine, says Young. Implementation strategies and linkage to other AAFP activities are evolving, as are the Academy’s relationships with other medical societies.
Toni Lapp
AAFP News Department
- © 2004 Annals of Family Medicine, Inc.