In Reply: A Bibliometric Analysis of Neurosurgical Practice Guidelines.

Abstract

To the Editor: The authors are appreciative of the interest generated by our recent publication, “A Bibliometric Analysis of Neurosurgical Practice Guidelines.”1 The letter to the editor2 on our article brings up an interesting discussion that warrants further exploration, ie, assets and barriers to successful implementation of clinical practice guidelines (CPGs). Several likely contributing factors are mentioned, including awareness of CPGs, agreement/disagreement with the recommendations, adequate skills to provide the recommended care, availability of needed resources, and, perhaps most importantly, the inertia of clinical habit. We included brief mention in our manuscript of some studies having identified similar barriers, and the letter's authors have cited several additional studies with consistent findings. In our opinion, the conclusion to be drawn from all of these studies is that there is an array of barriers that likely play a varying role in CPG uptake depending on the clinician, the clinician's practice location, the guideline, and the clinical scenario. In addition, the support of the hospital organization may be a key influence on guideline adoption.3 Of note, we certainly agree that neurosurgeons are not impervious to such obstacles; however, it is also possible that the barriers and overall perceptions of CPGs could be unique to neurosurgery compared to other surgical disciplines given the complex and diverse nature of the field and the greater than average risk of malpractice litigation.4 Such questions are worth asking5,6 and warrant further study. An additional question that is begged by the discussion is whether there are factors or interventions that might improve CPG implementation. The American Heart Association recently released a special report on the topic that found that interventions such as provider educational paradigms, audit and feedback, and reminders are effective in improving CPG adherence as well as clinical outcomes for cardiac disease.7 There is some indication within neurosurgery that these are important and potentially positive issues given that the first guideline published for neurosurgery, the closed head injury guidelines,8 were widely presented at national and international meetings of neurosurgeons, as well as within the state neurosurgical societies. Follow-up studies indicated that physician practice had initially not changed significantly.9 However, in response to the concerted efforts by neurosurgical organizations and the authors of the original guidelines, and growing overall national acceptance of the concept of evidence-based guidelines, and the acceptance as part of hospital protocols in Level 1 trauma units, this trend reversed dramatically.10 Perhaps the most important measure is to ensure that patient outcomes are improved by greater CPG adherence, as illustrated with the closed head injury guidelines.11 We would propose that dissemination is the first critical step in this process given that unless a clinician is made aware of new CPG recommendations, they cannot be followed. While citation metrics are admittedly a crude surrogate for dissemination, they do allow a unique cross-sectional lens through which to view the current landscape of neurosurgical guidelines. Prior to this study, bibliometrics had not been used for this purpose. We surmise that while citation analysis is no replacement for high quality implementation science, it is perhaps a useful marker, and intermittent repetitions of similar bibliometric analyses could serve as additional points of comparison with the current study. Echoing the letter to the editor's authors, we would like to conclude by reiterating what we consider to be the most important point of our paper. The neurosurgical community has made unequivocally clear that it prioritizes evidence and the production of high-quality evidence-based CPGs.12 This study has demonstrated that given our current strategy of implementation, there is a wide spectrum within the extent to which these documents are seen and in turn discussed in our literature. The next step in that process may be for the American Association of Neurological Surgeons/Congress of Neurological Surgeons Guidelines Committee to commission several studies with each newly published guideline that will evaluate its effectiveness in the form of physician behavior and patient outcomes at a pre-specified time interval from release. The authors are not aware of a similar strategy being used by any other medical or surgical discipline. Such intentionality in implementation would take neurosurgery to the forefront of evidence-based medicine and would very likely improve the quality of care given to our patients. The great advantage of the proposed strategy is that if it failed to improve outcomes, we would then be apprised of the failure, and be able to ascertain – and perhaps prevent – its causes. Disclosures The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.