The VA/DOD Clinical Practice Guideline for Management of Post- Traumatic Stress (update 2010): Development and Methodology

Abstract

CLINICAL PRACTICE GUIDELINES The Department of Veterans Affairs (VA)/Department of Defense (DOD) clinical practice guidelines (CPGs) are recommendations that are made to VA/DOD healthcare providers regarding their approaches to treatment of a variety of medical conditions. They are based on the best available clinical evidence and are designed to achieve the most desirable outcomes based on a variety of clinical situations. In general, CPGs have been defined as systematically developed statements to assist practitioner and patient in making decisions about appropriate healthcare for specific clinical circumstances [1]. CPGs are being used throughout healthcare systems as a means of enhancing quality, reducing costs, and optimizing performance. Good CPGs can change the process of healthcare and improve outcomes by providing recommendations for the management of patients and supporting the development of standards to assess outcomes. A CPG should also assist in healthcare providers' education and training, likewise educating the patients; help in making informed decisions; and improve communication between the patient and provider. A CPG, when implemented, will influence practice patterns. GUIDELINE DEVELOPMENT There have been many recommended approaches to CPG development methodologies. The World Health Organization (WHO) assessed models of CPG development used internationally and identified the following best practices in CPG development [2]: * Developed by multidisciplinary CPG development working groups (WGs). * Explicit, transparent use of systematic reviews of evidence to develop recommendations. * Documentation of the CPG development process (including disclosure of interest declarations at all levels of involvement). * Include ratings of the evidence associated with key recommendations. * Defined and explicit process for consultation and peer review of the draft CPG. * Multiple level outputs, including versions (modules) for specialists, primary care professionals, and patients. The development and the underlying principles of the process used to develop the VA/DOD CPGs are very much consistent with the principles described by the WHO and those practiced by other healthcare organizations that have developed CPGs (e.g., National Institute for Health and Clinical Excellence and Institute for Clinical Systems Improvement). The VA/DOD process is also consistent with the proposed eight standards for developing trustworthy CPGs published recently by the Institute of Medicine [3]. CPGs are usually developed by groups of clinicians. Clinicians regularly make difficult choices about treatment options. Often, there is uncertainty about the value of different options, and practice can vary widely. CPGs can be seen as one way of assisting clinicians in decision-making. In an ideal world, CPGs would be based on evidence derived from rigorously conducted empirical studies. In practice, there are only few areas of care where sufficient research based evidence exists. In such situations, the development of comprehensive CPGs will inevitably have to be based partly on consensus of the opinions and experience of clinicians and others in the subject at hand. A technology assessment published in 1998, reviewed 177 primary research and review articles that studied the factors that affect the decisions that emerge from consensus development approaches and assessed the implications of the findings for the development of CPGs [4]. A group consensus process brings to bear a wider range of direct knowledge and experience. The interaction among the group members can stimulate consideration of a wider range of options, and debates can challenge old ideas and generate new ones. However, several issues need to be addressed and pitfalls need to be avoided when a group of experts is attempting to reach consensus. For example, the choice and mixture of participants, the bias and conflict of interest they may bring with them, and the cost of bringing people together. …