GUIDELINE SHOWCASES AAFP’S COMMITMENT TO EVIDENCE-BASED, PATIENT-CENTERED CARE

The clinical practice guideline published as a supplement to the online version of this issue of the Annals of Family Medicine (http://www.annfammed.org/cgi/content/full/3/4/378/DC1) combines elements both unique and ubiquitous. The guideline, “Trial of Labor After Cesarean (TOLAC), Formerly Trial of Labor Versus Elective Repeat Cesarean Section for the Woman With a Previous Cesarean Section,” is unique in that it reflects family medicine’s patient-centered approach to care. At the same time, it embodies the AAFP’s dedication to promoting evidence-based medical practice—a hallmark of all clinical practice guidelines the Academy produces.

The TOLAC guideline and its recommendations offer guidance for pregnant women and their families, health professionals and facilities that provide maternity care, and health policy makers with an interest in this area of maternity care. An executive summary of the guideline, including the practice recommendations, appears in Table 1⇓.

The rigorous process the Academy uses to develop its clinical practice guidelines begins with the identification of clinically relevant topics. The AAFP Commission on Clinical Policies and Research (CCPR) has established criteria it uses to select topics important to family physicians and their patients.

The next step is to perform or obtain a systematic review of all the available evidence on a given topic. To this end, the Academy usually avails itself of the services of the Agency for Healthcare Research and Quality (AHRQ) and its Evidence-based Practice Centers (EPCs).

AHRQ partners with private and public organizations to support their efforts to improve the quality, effectiveness, and appropriateness of health care delivery in the United States. Professional societies, health systems, employers, insurers, consumer groups, and others may nominate topics for scientific analysis and evidence synthesis. AHRQ supports about 9 evidence reports each year.

These organizational partners are, in turn, expected to serve as resources to the EPCs as they develop the evidence reports related to the nominated topics, including serving as external peer reviewers of draft evidence reports. The organizations also commit to timely translation of the evidence reports into clinical practice guidelines, performance measures, educational programs, and/or reimbursement policies. Finally, the partners agree to disseminate these derivative products to their memberships.

In the case of the TOLAC guideline, the topic was nominated to AHRQ independently by both the Academy and American College of Obstetricians and Gynecologists. The evidence synthesis, performed by AHRQ’s Oregon EPC (Oregon Health & Science University in Portland), was released in March 2003. The executive summary of that evidence report, titled “Vaginal Birth After Cesarean (VBAC),” is available at http://www.ahrq.gov/clinic/epcsums/vbacsum.htm.

Specific questions examined during the VBAC evidence synthesis addressed such issues as the frequency of successful vaginal delivery in women who undergo a trial of labor (TOL) after a previous low transverse cesarean; accuracy of risk-assessment tools in identifying patients likely to have a successful vaginal delivery after a TOL; and relative harms associated with a TOL versus repeat cesarean, including the incidence of uterine rupture.

AAFP guideline panels are composed of members of the CCPR and additional experts in content and methodology. The goal is to convene a panel of family physicians representing both community and academic practice settings to ensure the clinical relevance of the resulting practice guideline for all family physicians. In the case of the TOLAC guideline, a panel of family physicians with particular expertise in this area of maternity care reviewed the VBAC report findings, conducted a systematic update of the evidence by reviewing studies published since the report was released and created the guideline.

Components of the TOLAC guideline include background information: the rationale for developing the guideline; a review of the methodology used to create the guideline; results of the evidence review; a set of practice recommendations, including summaries of the quality of evidence for each recommendation; and suggestions for future research in this area.

Once an AAFP clinical practice guideline panel has completed its work, the guideline is peer-reviewed by members of the CCPR and other content experts as appropriate. The full CCPR and the AAFP Board of Directors must approve the guideline before it becomes official Academy policy. AAFP clinical policies are reviewed every 5 years and are at that time reaffirmed, revised, or removed.

Whenever practicable, the AAFP collaborates with other specialty medical organizations—primarily those whose members deliver primary health care services—and occasionally with subspecialty medical and even patient advocacy groups to permit development of a single clinical practice guideline that can be applied in various primary care settings. The rationale for this process: Creating a single set of comprehensive, evidence-based practice guidelines reduces the burden on busy practicing physicians and avoids the potential for patient confusion posed by differing guidelines.

Generally, the Academy collaborates with the American College of Physicians (ACP) on guidelines relating to adults. Most recently, AAFP and ACP published jointly developed guidelines for atrial fibrillation and migraine headache. The 2 organizations are currently developing joint guidelines on 3 different topics: diagnosis and management of venous thromboembolism, pharmacologic management of dementia, and management of impaired glucose tolerance.

For guidelines relating to children, the Academy collaborates with the American Academy of Pediatrics. The 2 groups most recently published jointly developed guidelines on managing acute otitis media and on treatment for otitis media with effusion.

See Table 2⇓ for additional information on evidence-based clinical practice guidelines developed by the AAFP either alone or in conjunction with other groups. All of the Academy’s clinical policy statements and recommendations may be accessed at http://www.aafp.org/x132.xml.

• © 2005 Annals of Family Medicine, Inc.