Association Clinical Practice Guidelines Research Articles

Use of the American Urological Association Clinical Practice Guidelines: Data from the AUA Census

IntroductionThrough systematic data review and expert consensus, the AUA (American Urological Association) produces clinical practice guidelines that serve to provide evidence-based guidance with an explicit clinical scope and purpose. In this study we determined whether urologists use clinical practice guidelines when making clinical decisions, and whether demographic factors are associated with not using the guidelines or with a lack of guideline awareness. MethodsWe examined the 2014 AUA Census. Our outcome was a question regarding whether the participant used AUA clinical practice guidelines in clinical decision making. We performed comparative statistical analyses, stratifying our outcome by demographic and practice specific variables. ResultsA total of 2,204 urologists completed the census, representing 18.9% of practicing urologists in the United States. Median age was 53 years and 91.1% were male. The majority of urologists used clinical practice guidelines (94.8%) in clinical decision making. Clinical practice guidelines had the lowest use among urologists 65 years old or older (89.2%), those in solo practice (88.3%) and pediatric specialists (87.9%). Based on a multivariable logistic regression analysis, factors associated with not using clinical practice guidelines included increasing age, metropolitan practice setting and solo practice. Gender, AUA section, level of rurality and fellowship training were not statistically associated with clinical practice guideline use. ConclusionsThe majority of urologists (approximately 95%) use AUA clinical practice guidelines to inform clinical decisions. Our findings support the importance of clinical practice guidelines and highlight potential opportunities for better targeted outreach to improve clinical practice guideline use among practicing urologists.

Cardiovascular Risk Assessment: A Systematic Review of Guidelines.

Many guidelines exist for screening and risk assessment for the primary prevention of cardiovascular disease in apparently healthy persons. To systematically review current primary prevention guidelines on adult cardiovascular risk assessment and highlight the similarities and differences to aid clinician decision making. Publications in MEDLINE and CINAHL between 3 May 2009 and 30 June 2016 were identified. On 30 June 2016, the Guidelines International Network International Guideline Library, National Guideline Clearinghouse, National Library for Health Guidelines Finder, Canadian Medical Association Clinical Practice Guidelines Infobase, and Web sites of organizations responsible for guideline development were searched. 2 reviewers screened titles and abstracts to identify guidelines from Western countries containing recommendations for cardiovascular risk assessment for healthy adults. 2 reviewers independently assessed rigor of guideline development using the Appraisal of Guidelines for Research and Evaluation II instrument, and 1 extracted the recommendations. Of the 21 guidelines, 17 showed considerable rigor of development. These recommendations address assessment of total cardiovascular risk (5 guidelines), dysglycemia (7 guidelines), dyslipidemia (2 guidelines), and hypertension (3 guidelines). All but 1 recommendation advocates for screening, and most include prediction models integrating several relatively simple risk factors for either deciding on further screening or guiding subsequent management. No consensus on the strategy for screening, recommended target population, screening tests, or treatment thresholds exists. Only guidelines developed by Western national or international medical organizations were included. Considerable discrepancies in cardiovascular screening guidelines still exist, with no consensus on optimum screening strategies or treatment threshold. Barts Charity.

Preoperative Evaluation of the Vascular Patient

Almost as critical as an operation itself is the preparation of the patient. Although this often includes psychosocial concerns such as expectations of recovery, inpatient stay, and other patient-centered issues, the discussion prior to surgery should not be limited to these factors. A medical assessment of the patient’s fitness and physiologic preparedness for the planned procedure must be performed by the surgeon and the resultant findings and plan reviewed with the patient. Although vascular disease affects multiple organ systems requiring a thorough general preoperative patient assessment, the focus of preoperative risk reduction strategies center on cardiac outcomes. Therefore, this review focuses on cardiac-related interventions with added coverage of preoperative strategies regarding diabetes, pulmonary and renal risk assessment, and infection reduction. Lastly, the perioperative management of anticoagulation/antiplatelet medications and cerebrovascular disease are discussed Techniques and treatments to optimize patients for surgery are integrated into the respective sections, allowing for a primer to guide this critical phase in a patient’s journey through surgery. Tables outline the Revised Cardiac Risk Index, assessment of functional capacity from patient self-reported activities, optimal delay in elective surgery after percutaneous coronary revascularization according to the 2014 American College of Cardiology/American Heart Association clinical practice guidelines, Respiratory Failure Risk Index, Szilagyi classification of vascular surgical site infection, and recommendations regarding perioperative management of anticoagulants and antiplatelet agents. A suggested algorithm for preoperative cardiac workup and the Cockcroff-Gault equation are provided. This review contains 2 figures, 6 tables, and 115 references.

Review of Dietary Practices of the 21st Century: Facts and Fallacies.

The prevalence of chronic metabolic diseases, such as diabetes, cardiovascular diseases and cancer, is increasing around the world. Nutritional interventions can reduce the prevalence and provide effective treatment, even when weight loss is not dramatic. The 2013 Canadian Diabetes Association Clinical Practice Guidelines concluded that certain dietary patterns and popular weight-loss diets had sufficient evidence to suggest their use by individuals with diabetes, but many other diet patterns and diets exist. Our specific objectives were to review the nutritional quality of various dietary patterns and diets, with emphasis on the evidence that they are efficacious for weight loss, glycemic control and cardiovascular risk factors.

LO067: Emergency department management of diabetic ketoacidosis and hyperosmolar hyperglycemic state: national survey of attitudes and practice

Introduction: The 2011 Canadian Diabetes Association (CDA) Clinical Practice Guidelines were developed in order to help physicians manage hyperglycemic emergencies in the emergency department (ED), including diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). The goal of this study was to determine physician attitudes towards these guidelines and to identify potential barriers to their implementation in the ED. Methods: We distributed an online, cross sectional survey to 500 randomly selected members of the Canadian Association of Emergency Physicians (CAEP) who were currently practicing physicians. A total of 3 email notifications were distributed on days 1, 7 and 14. The survey consisted of 23 questions relating to physician management of DKA and HHS in the ED. The primary outcome was overall physician familiarity and usage of the guidelines using a 7-point Likert scale. Secondary outcomes included physician attitudes towards the guidelines as well as any perceived barriers to their implementation in the ED. Simple descriptive statistics were used to illustrate the survey results. Results: The survey response rate was 62.2% (311/500) with the following participant characteristics: male (62.6%), CCFP(EM) training (46.1%) and working in major academic centers (50.5%). The overall awareness rate of the CDA guidelines was 22.9% (95% CI = 18.3%, 27.5%). 58.9% (95% CI = 53.3%, 64.3%) reported the CDA guidelines being useful. The most frequently reported barriers to CDA guideline implementation were concerns about education issues (56.0%), lack of time and disruption of flow (23.9%), staffing and human resource issues (26.7%) and poor policy adherence (25.5%). Physician’s ideal changes to optimize the management of these patients included improved coordination for follow-up with family physicians (79.9%), increased diabetes education for patients (73.9%) and increased availability to diabetes specialists (47.5%). Conclusion: In this study, although Canadian ED physicians were generally supportive of the CDA guidelines, many were unaware that these guidelines existed and barriers to their implementation were reported. Future research should focus on strategies to standardize DKA and HHS management by ensuring physician awareness and education to ensure the highest quality of patient care.

A 2015 Survey of Clinical Practice Patterns in the Management of Thyroid Nodules.

The management of thyroid nodules has changed dramatically over the past two decades. In the interim, technological advances including high-resolution ultrasound and molecular testing of thyroid nodules have been introduced. We sought to document current practices in the management thyroid nodules and assess the extent to which technological advances have been incorporated into current practice. We further sought to compare current practice to recommendations made in a recently updated American Thyroid Association (ATA) clinical practice guideline (CPG) and examine differences in thyroid nodule management among international members of U.S.-based endocrine societies. Members of The Endocrine Society, ATA, and American Association of Clinical Endocrinologists were invited to participate in a Web-based survey dealing with testing, treatment preference, and modulating factors in patients with thyroid nodules. A total of 897 respondents participated in the survey, including 661 members of The Endocrine Society, 454 American Association of Clinical Endocrinologists members, and 365 ATA members. Thyroid fine-needle aspiration (FNA) in 2015 is generally performed by endocrinologists (56.6%) and radiologists (31.9%), most frequently using ultrasound guidance (83.3%). Respondents in general have a lower threshold for FNA of thyroid nodules than that recommended in the updated ATA CPG. Management depends on the FNA result, with follicular lesion of undetermined significance/atypia of undetermined significance resulting in molecular testing (38.8% of respondents), repeat FNA cytology (31.5%), or immediate referral for thyroid surgery (24.4%). Nodules showing follicular neoplasm by FNA are referred for thyroid surgery by 61.2% of respondents (46.6 % lobectomy, 14.6 % total thyroidectomy) or molecular testing (29.0 %). Nodules found suspicious but not conclusive for malignancy (Bethesda category V), are referred for thyroid surgery (86.0%) and rarely undergo molecular testing (9.5%). During pregnancy, only 47.6% of respondents would perform FNA in the absence of nodular growth, with most respondents deferring FNA until after pregnancy. Endocrinologists are 64.2% less likely to perform FNA in an octogenarian than a younger patient with a comparable thyroid nodule. Striking international differences were identified in the routine measurement of calcitonin and in the use of molecular testing of thyroid nodules. In summary, our survey of clinical endocrinologists on the management of thyroid nodules documents current practice patterns and demonstrates both concordance and focal discordance with recently updated CPGs. Both international differences and a change in practice patterns during the past two decades are demonstrated.

A survey of views and practice patterns of dialysis medical directors toward end-of-life decision making for patients with end-stage renal disease

Background: Patients with end-stage renal disease report infrequent end-of-life discussions, and nephrology trainees report feeling unprepared for end-of-life decision making, but the views of dialysis medical directors have not been studied. Aim: Our objective is to understand dialysis medical directors’ views and practice patterns on end-of-life decision making for patients with ESRD. Design: We administered questionnaires to dialysis medical directors during medical director meetings of three different dialysis organizations in 2013. Survey questions corresponded to recommendations from the Renal Physicians Association clinical practice guidelines on initiation and withdrawal of dialysis. Setting/participants: There were 121 medical director respondents from 28 states. Results: The majority of respondents felt “very prepared” (66%) or “somewhat prepared” (29%) to participate in end-of-life decisions and most (80%) endorsed a model of shared decision making. If asked to do so, 70% of the respondents provided prognostic information “often” or “nearly always.” For patients with a poor prognosis, 36% of respondents would offer a time-limited trial of dialysis “often” or “nearly always”, while 56% of respondents would suggest withdrawal from dialysis “often” or “nearly always” for those with a poor prognosis currently receiving dialysis therapy. Patient resistance and fear of taking away hope were the most commonly cited barriers to end-of-life discussions. Conclusion: Views and reported practice patterns of medical directors are consistent with clinical practice guidelines for end-of-life decision making for patients with end-stage renal disease but inconsistent with patient perceptions.

Nephrologist-Facilitated Advance Care Planning for Hemodialysis Patients: A Quality Improvement Project.

The Renal Physicians Association's clinical practice guideline recommends that physicians address advance care planning with dialysis patients. However, data are lacking about how best to implement this recommendation. Quality improvement project. Nephrologists caring for patients treated with maintenance hemodialysis at 2 dialysis facilities identified patients who might benefit most from advance care planning using the "surprise" question ("Would I be surprised if this patient died in the next year?"). Patients identified with a "no" response to the surprise question were invited to participate in nephrologist-facilitated advance care planning, including completion of a Medical Orders for Life-Sustaining Treatment (MOLST) form. Change in MOLST completion rate and identification of preferences for limits on life-sustaining treatment. Pre- and postintervention code status, MOLST completion rate, and vital status at 1 year. Nephrologists answered "no" to the surprise question for 50 of 201 (25%) hemodialysis patients. Of these, 41 (82%) patients had a full-code status and 9 (18%) had a do-not-resuscitate (DNR) status. Encounters lasted 15 to 60 minutes. Following the encounter, 21 (42%) patients expressed preference for a DNR status and 29 (58%) maintained full-code status (P=0.001). The MOLST completion rate increased from 10% to 90%. One-year survival for patients whose nephrologists answered "no" to the surprise question was 58% compared to 92% for those with a "yes" answer (P<0.001). Sample size and possible nonrepresentative dialysis population. Nephrologist-facilitated advance care planning targeting hemodialysis patients with limited life expectancy led to significant changes in documented patient preferences for cardiopulmonary resuscitation and limits on life-sustaining treatment. These changes demonstrate the benefit of advance care planning with dialysis patients and likely reflect better understanding of end-of-life treatment options.

Management of Diabetic Nephropathy

There are a few changes in the management of diabetic nephropathy (DN) in 2015 Korean Diabetes Association (KDA) Clinical Practice Guideline. Among them, restricting protein intake in patients with DN has been in controversy. Several guidelines in other countries recommend not to reduce the daily protein intake less than 0.8 g/kg/day in patients with DN, which is in agreement with the KDA guideline. Although the current KDA recommendation does not comment about high protein intake, several guidelines warn a high protein intake (> 1.3 g/kg/day) since it aggravates the progression of DN. The other issue is a target blood pressure (BP) in DN. It has been recommended that BP should be maintained at a lower level in patients with DN than in diabetic patients without nephropathy. Recently, failure to demonstrate the beneficial effects of lowering BP in reducing mortality or cardiovascular disease lead to increase the optimal BP target in diabetes from 130/80 to 140/90 mm Hg. Therefore, BP target should be individualized based on their comorbidities and life expectancy in DN patients. In this section, we recommend the optimization of BP control to reduce the risk or slow the progression of DN, rather than specify target BP levels.

Treatment-Based Classification System for Low Back Pain: Revision and Update.

The treatment-based classification (TBC) system for the treatment of patients with low back pain (LBP) has been in use by clinicians since 1995. This perspective article describes how the TBC was updated by maintaining its strengths, addressing its limitations, and incorporating recent research developments. The current update of the TBC has 2 levels of triage: (1) the level of the first-contact health care provider and (2) the level of the rehabilitation provider. At the level of first-contact health care provider, the purpose of the triage is to determine whether the patient is an appropriate candidate for rehabilitation, either by ruling out serious pathologies and serious comorbidities or by determining whether the patient is appropriate for self-care management. At the level of the rehabilitation provider, the purpose of the triage is to determine the most appropriate rehabilitation approach given the patient's clinical presentation. Three rehabilitation approaches are described. A symptom modulation approach is described for patients with a recent-new or recurrent-LBP episode that has caused significant symptomatic features. A movement control approach is described for patients with moderate pain and disability status. A function optimization approach is described for patients with low pain and disability status. This perspective article emphasizes that psychological and comorbid status should be assessed and addressed in each patient. This updated TBC is linked to the American Physical Therapy Association's clinical practice guidelines for low back pain.

The association between self-monitoring of blood glucose, hemoglobin A1C and testing patterns in community pharmacies: Results of a pilot study.

To determine if pharmacists providing advice on self-monitoring of blood glucose (SMBG) to new meter users, based on the Canadian Diabetes Association (CDA) Clinical Practice Guidelines (CPGs), resulted in improvements in A1C. SMBG testing patterns and pharmacist interactions were also observed. A cluster randomized, pilot study was performed, with pharmacies randomized to an intervention or control group. The intervention group provided SMBG education according to the CDA CPGs at baseline, 2 weeks, 1 month and 3 months; the control group provided usual care. The primary endpoint was the mean change in A1C measured at 6 months. Secondary endpoints included a description of SMBG patterns and lifestyle changes and were determined via a self-administered questionnaire. Thirty-six participants (26 intervention, 10 control) were recruited from 9 pharmacies across Saskatchewan, Canada. Mean A1C decreased by -1.69 and -0.70 in the intervention and control groups, respectively (p = 0.376). A total of 12 of 26 (46.2%) participants in the intervention group indicated they performed SMBG ≥7 times per week; 75% (9/12) of these were controlled by lifestyle or metformin alone. When applicable, most participants in the intervention group indicated they perform SMBG with exercise (62.5%), during illness (62.5%) and with hypoglycemic symptoms (81.3%) compared with 33.3%, 42.9% and 42.9% in the control group, respectively. Most participants in the intervention group (20/26; 76.9%) reported making lifestyle changes as a result of speaking with the pharmacist, with all indicating that they maintained these changes at 6 months. The results of this pilot study indicate that a larger study examining pharmacist interventions related to SMBG is feasible. Future studies are required to determine patient motivations and further evaluate the role of pharmacists in ensuring best practices to positively influence guideline-based blood glucose monitoring.

Impact of Current and Emerging Glucose-Lowering Drugs on Body Weight in Type 2 Diabetes.

Type 2 diabetes is a progressive disease, and most people with diabetes will eventually require adjunctive pharmacotherapy to optimize their glycemic control. As the majority of people with type 2 diabetes are overweight or obese, weight management is an essential component of diabetes management to improve their overall health and quality of life. Many of the currently available glucose-lowering drugs are associated with weight gain, which makes it challenging for both prescribing clinicians and patients. The 2015 Canadian Diabetes Association Clinical Practice Guidelines interim update on the pharmacologic management of type 2 diabetes recommend individualization of therapy and glycemic targets. Clinicians should take into consideration not only the drug's efficacy and safety profiles but also its propensity for causing hypoglycemia and weight gain. Given that the number of glucose-lowering drugs is expanding rapidly, a better understanding of the impacts of current and emerging therapies on body weight will serve as a useful guide. Metformin remains the first-line drug after diet and exercise therapy. The next add-on agent could be selected from the incretin or sodium-glucose cotransporter-2 inhibitor class because these drugs rarely cause hypoglycemia and may lead to modest weight loss. When insulin therapy is considered, choosing a basal insulin that is associated with less nocturnal hypoglycemia and weight gain is recommended. Emerging therapies using combination therapy of an incretin-sodium-glucose cotransporter 2 inhibitor or glucagon-like peptide-1 agonist-basal insulin hold promise to achieve robust glycemic control with weight loss and low risk for hypoglycemia.

Kidney Paired Donation Protocol for Participating Donors 2014.

Kidney Paired Donation Protocol for Participating Donors 2014.

Update on perioperative care of the cardiac patient for noncardiac surgery.

The current review will address key topics and recommendations of the recent 2014 update of the American College of Cardiology and American Heart Association clinical practice guideline for the perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. The completely rewritten guideline provides a stepwise approach for the identification and management of patients at highest risk for major adverse cardiac events and discusses new or updated recommendations. For example, β-blockers should be continued perioperatively but treatment should not be initiated within 24 h of noncardiac surgery. Angiotensin-converting enzyme inhibitors should be continued, but if held, may be restarted as soon as feasible. Routine aspirin therapy is not recommended without previous coronary stent implantation or risk assessment for myocardial ischemia. Elective noncardiac surgery should not be performed within 30 days of bare metal stent or 12 months of drug-eluting stent implantation because of in-stent thrombosis as well as bleeding risk from dual antiplatelet therapy during surgery. Noncardiac surgery may be considered, however, in patients on antiplatelet agents 180 days after drug-eluting stent placement if risk of surgical delay exceeds risk of stent thrombosis from cessation of antiplatelet therapy. In conclusion, this review will discuss the important topics from the 2014 American College of Cardiology/American Heart Association guideline in order to provide the perioperative physician with the most recent evidence necessary to minimize major adverse cardiac events in patients undergoing noncardiac surgery.

2015 SCAI/ACC/HFSA/STS Clinical Expert Consensus Statement on the Use of Percutaneous Mechanical Circulatory Support Devices in Cardiovascular Care (Endorsed by the American Heart Association, the Cardiological Society of India, and Sociedad Latino Americana de Cardiologia Intervencion; Affirmation of Value by the Canadian Association of Interventional Cardiology–Association Canadienne de Cardiologie d'intervention)

Although historically the intra-aortic balloon pump has been the only mechanical circulatory support device available to clinicians, a number of new devices have become commercially available and have entered clinical practice. These include axial flow pumps, such as Impella®; left atrial to femoral artery bypass pumps, specifically the TandemHeart; and new devices for institution of extracorporeal membrane oxygenation. These devices differ significantly in their hemodynamic effects, insertion, monitoring, and clinical applicability. This document reviews the physiologic impact on the circulation of these devices and their use in specific clinical situations. These situations include patients undergoing high-risk percutaneous coronary intervention, those presenting with cardiogenic shock, and acute decompensated heart failure. Specialized uses for right-sided support and in pediatric populations are discussed and the clinical utility of mechanical circulatory support devices is reviewed, as are the American College of Cardiology/American Heart Association clinical practice guidelines.

2015 SCAI/ACC/HFSA/STS Clinical Expert Consensus Statement on the Use of Percutaneous Mechanical Circulatory Support Devices in Cardiovascular Care (Endorsed by the American Heart Association, the Cardiological Society of India, and Sociedad Latino Americana de Cardiologia Intervencion; Affirmation of Value by the Canadian Association of Interventional Cardiology-Association Canadienne de Cardiologie D'intervention).

Although historically the intra-aortic balloon pump has been the only mechanical circulatory support device available to clinicians, a number of new devices have become commercially available and have entered clinical practice. These include axial flow pumps, such as Impella®; left atrial to femoral artery bypass pumps, specifically the TandemHeart; and new devices for institution of extracorporeal membrane oxygenation. These devices differ significantly in their hemodynamic effects, insertion, monitoring, and clinical applicability. This document reviews the physiologic impact on the circulation of these devices and their use in specific clinical situations. These situations include patients undergoing high-risk percutaneous coronary intervention, those presenting with cardiogenic shock, and acute decompensated heart failure. Specialized uses for right-sided support and in pediatric populations are discussed and the clinical utility of mechanical circulatory support devices is reviewed, as are the American College of Cardiology/American Heart Association clinical practice guidelines.

Preoperative Evaluation of the Vascular Patient

Almost as critical as an operation itself is the preparation of the patient. Although this often includes psychosocial concerns such as expectations of recovery, inpatient stay, and other patient-centered issues, the discussion prior to surgery should not be limited to these factors. A medical assessment of the patient’s fitness and physiologic preparedness for the planned procedure must be performed by the surgeon and the resultant findings and plan reviewed with the patient. Although vascular disease affects multiple organ systems requiring a thorough general preoperative patient assessment, the focus of preoperative risk reduction strategies center on cardiac outcomes. Therefore, this review focuses on cardiac-related interventions with added coverage of preoperative strategies regarding diabetes, pulmonary and renal risk assessment, and infection reduction. Lastly, the perioperative management of anticoagulation/antiplatelet medications and cerebrovascular disease are discussed Techniques and treatments to optimize patients for surgery are integrated into the respective sections, allowing for a primer to guide this critical phase in a patient’s journey through surgery. Tables outline the Revised Cardiac Risk Index, assessment of functional capacity from patient self-reported activities, optimal delay in elective surgery after percutaneous coronary revascularization according to the 2014 American College of Cardiology/American Heart Association clinical practice guidelines, Respiratory Failure Risk Index, Szilagyi classification of vascular surgical site infection, and recommendations regarding perioperative management of anticoagulants and antiplatelet agents. A suggested algorithm for preoperative cardiac workup and the Cockcroff-Gault equation are provided. This review contains 2 figures, 6 tables, and 115 references.

Evidence-based nursing review of craniectomy care.

Interest in decompressive craniectomy (DC) to manage neurological emergencies including stroke has waxed and waned for decades. The best evidence for the use of DC is in patients with refractory cerebral edema related to large territory ischemic stroke. Although many publications have evaluated the role of craniectomy in managing neurological emergencies, none outline care priorities for patients who have received the procedure. Although the use of DC to manage stroke, intracerebral hemorrhage (ICH), or subarachnoid hemorrhage (SAH) represents a minority of patients, those undergoing craniectomy are the most acutely ill and vulnerable patient population. In review of the American Heart Association/American Stroke Association clinical practice guidelines for management of stroke, DC is mentioned as a life-saving procedure. However, little is mentioned about the organization of care of the patient who has undergone DC. We conducted a narrative, comprehensive review of the literature aimed at to define the specific care needs of a patient with stroke who receives craniectomy. Search terms included craniectomy in multiple variations, ischemic stroke, ICH, SAH, complications, and nursing care. More than 60 publications were reviewed. No trials or reviews that addressed the unique or specific care needs of patient were found. When the initial search of the literature revealed a dearth of information beyond indications for the use of DC and complications, the team altered course to understand the care priorities based on complications associated with the procedure. From the review, a summary of nursing care priorities was generated. In addition, priorities for future research were identified. DC associates with several unique complications. Although the frequency of any 1 complication may be low, case series indicate that the over frequency of complications may be high for patient after DC.1 However, the quantification of complications is difficult as many reports are single site experiences with a …

Testing for albuminuria in 2014.

Routine quantification of urinary albumin levels is recommended for all Canadians with diabetes, yet many controversies remain when interpreting these tests. Elevated levels of albuminuria have traditionally been labeled as either microalbuminuria, representing 30 to 300 mg of albuminuria per day (a range not reliably picked up by conventional urine dipsticks), or as overt nephropathy, representing more than 300 mg per day and usually identifiable by dipstick. The random urine albumin-to-creatinine ratio is a convenient test that can predict reliably the total daily protein excretion. The 30 mg per day upper limit of normal was selected to be a threshold far above the normal albumin excretion seen in healthy people. However, recent studies have shown that elevations of albumin excretion below the microalbuminuria threshold are associated with increased cardiorenal risk, suggesting that the 30 mg per day level may be set too high. Recently, the Canadian Diabetes Association Clinical Practice Guidelines changed the threshold for abnormal urine albumin-to-creatinine ratios to be 2.0 mg/mmol for both men and women. As a result, more women will be identified as having abnormal levels of albuminuria. However, these women will be correctly identified as having increased cardiorenal risk. It is important to note that people with diabetes who have abnormal levels of albuminuria are among patients at the highest risk for cardiorenal disease. These risks can be reduced by using the strategies outlined in the guidelines put forth by the Canadian Diabetes Association.

The evolution and future of ACC/AHA clinical practice guidelines: a 30-year journey: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines.

In 2014, we mark the 30th anniversary of the first publication of an American College of Cardiology (ACC) and American Heart Association (AHA) clinical practice guideline (CPG). This joint effort was undertaken in response to the US government’s request to review the evidence concerning cardiac pacemakers and develop CPGs to mitigate potential overuse. Since then, fueled by a shared sense of responsibility to translate available evidence into clinical practice to guide cardiovascular clinicians, the ACC and AHA have developed 23 CPGs across the spectrum of cardiovascular diseases and procedures. The “why” and “how” of CPGs continue to evolve. Although the “why” is based on the directive to develop evidence-based recommendations for selection of diagnostic tests, procedures, and treatments to improve quality of care and outcomes for patients with cardiovascular disease, it is precisely where evidence is lacking or is controversial that clinicians need the most guidance. A 2012 survey of ACC and AHA members provides important insight into the way clinicians and other healthcare professionals apply CPGs; further details are provided below. The results highlight a natural tension between the needs of clinicians for comprehensive clinical advice from seasoned experts and for a clear delineation of diagnostic and therapeutic measures for which strong scientific evidence exists. Notably, there has been an increased focus on the “how” of CPGs and changes in the methodology used to collect and evaluate the evidence. In 2011, the Institute of Medicine (IOM) published 2 reports, Clinical Practice Guidelines We Can Trust 1 and Finding What Works in Health Care: Standards for Systematic Reviews .2 In response to these reports and our own mandate to continually improve processes and methods while evaluating the continuous stream of new knowledge and maintaining relevance at the point of care, the ACC/AHA Task Force on Practice Guidelines (Task Force) …