Abstract
BackgroundClinical guidelines are developed to lower risks, mostly viewed upon as probability. However, in daily practice, risk is perceived as the combination of probability and the impact of desired and adverse events. This combination of probability and impact can be visualized in a risk matrix. We evaluated the effect of interventions and diagnostic thresholds on modeled risk, by using the risk matrix approach (RMA) in a clinical guideline development process, and investigated which additional factors affected choices.MethodsTo improve care outcomes, we developed new guidelines in which care professionals had to decide upon novel interventions and diagnostic thresholds. A risk matrix showed the probability and impact of an intervention, together with the corresponding risk category. First, professionals’ opinion on required performance characteristics on risk were evaluated by a qualitative online survey. Second, qualitative assessment of possible additional factors affecting final decisions, that followed from group discussion and guideline development were evaluated.ResultsUpfront, professionals opinioned that non-invasive interventions should decrease the general population risk, whereas invasive interventions should decrease the risk in high-risk groups. Nonetheless, when making guidelines, interventions were introduced without reaching the predefined threshold of desired risk reduction. Professionals weighed other aspects besides risk reduction, as financial aspects and practical consequences for daily practice in this guideline-making process.ConclusionProfessionals are willing to change policies at much lower level of anticipated effectiveness than defined upfront. Although objectively presented data structured group discussions, decisions in guideline development are affected by several other factors than risk reduction alone.
Highlights
Clinical guidelines are developed to lower risks, mostly viewed upon as probability
We evaluated the effect of interventions and diagnostic thresholds on risk, using a risk matrix approach (RMA), and factors influencing the decision-making process towards the development of new guidelines and protocols
The Agreement Conform Current Operational Rules and Directives (ACCORD)-tool consists of a four-step bottom-up approach: first summarize current evidence on a specific topic based on existing guidelines, second translate evidence into statements, third send statements in an online survey (Survey Monkey, Palo, Alto, CA, USA) to the professionals to rank statements by level of agreement on a 10-point Likert-scale (1 totally disagree - 10 totally agree), and fourth review the survey results within a team of mandated representatives to make decisions on best given care
Summary
Clinical guidelines are developed to lower risks, mostly viewed upon as probability. In daily practice, risk is perceived as the combination of probability and the impact of desired and adverse events. We evaluated the effect of interventions and diagnostic thresholds on modeled risk, by using the risk matrix approach (RMA) in a clinical guideline development process, and investigated which additional factors affected choices. Healthcare professionals discuss risk and usually weigh the probability of an event occurring. Prior to introducing a new intervention or diagnostic threshold, professionals and policy makers have to consider what level of risk they would accept and what the expected effect of a newly introduced intervention is. When deciding upon new interventions or strategies, these novel actions should at least prevent or lower the risk of an adverse event to occur. Given the paradigm, it may be that professionals, policymakers or even patients may decide differently on the same questions raised
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