Introduction
Why Is the APA Developing Practice Guidelines?
How Are Practice Guidelines Developed?
What Are the Potential Benefits of This Project?
What Are the Possible Risks?
How Can We Improve the Current Process?
Quick Reference Guides
Online CME
Conclusions
The term practice guideline refers to a set of patient care strategies
developed to assist physicians in clinical decision making. The American Psychiatric
Association (APA) is continually developing new and revised guidelines, which are
published as they are completed.
APA recognizes that guideline recommendations are most useful if they are current.
As a result, APA releases “guidelines watches” as necessary. Watches
briefly describe major developments in the scientific literature since original
guideline publication. Watches may be authored and reviewed by experts associated
with the original guideline development effort and are approved for publication
by APA's Executive Committee on Practice Guidelines. Thus, watches represent opinion
of the authors and approval of the Executive Committee but not policy of the APA.
Readers should note that these parameters of care are indeed “guidelines”
and are not intended to be “standards of care.” These guidelines do
not necessarily include all proper methods of care for a particular disorder. The
ultimate judgment concerning the selection and implementation of a specific plan
of treatment must be made by the psychiatrist in light of the clinical data presented
by the patient and the diagnostic and treatment options available. Further description
of the intended role of the practice guidelines can be found in the
Statement of Intent.
Although the APA has published specific recommendations about the practice of psychiatry
since 1851, the commitment of resources to the practice guideline development process
since 1991 represents a qualitative change in the APA's role in establishing guidelines.
Such a change raises many questions.
Why Is the APA Developing Practice Guidelines?
For nearly 150 years, the APA's fundamental aim in developing practice guidelines
has been to assist psychiatrists in their clinical decision making, with the ultimate
goal of improving the care of patients. The explosion of knowledge in our field
over the last several decades amplifies the value of these guidelines. Furthermore,
the current health care climate is characterized by concerns about quality of care,
access to care, and cost. Efforts to respond to these problems by exerting external
control over the types and amount of care that can be provided have led to new concerns
about the quality of the data on which such efforts are based and the process by
which the data are used to determine “appropriate” or “reimbursable”
care. The realization that both treatment and reimbursement decisions are occurring
without systematic scientific and clinical input has led the APA, along with many
other medical specialty societies, to accelerate the process of documenting clearly
and concisely what is known and what is not known about the treatment of patients.
Although there are a number of other groups, including the federal and state governments,
managed care organizations, and care delivery systems, that are also developing
practice guidelines, the APA has decided that the psychiatric profession should
take the lead in describing the best treatments and the range of appropriate treatments
available to patients with mental illnesses.
How Are Practice Guidelines Developed?
The APA practice guidelines are developed under the direction of the Steering Committee
on Practice Guidelines. The process is designed to ensure the development of reliable
and valid guidelines and is consistent with the recommendations of the American
Medical Association and the Institute of Medicine. It is characterized by rigorous
scientific review of the available literature, widespread review of iterative drafts,
and ultimate approval by the APA Assembly and Board of Trustees. The APA is committed
to revising the guidelines at 5-year intervals. A revision may be accelerated if
there is substantial new evidence suggesting a change in preferred treatment approaches.
The development process is fully described here.
Between guideline revisions, “guideline watches” highlight significant
developments relevant to specific guideline recommendations. As they are completed,
watches are made available online here at www.PsychiatryOnline.com. Psychiatrists
who use the guidelines are advised to check the web site periodically to stay informed
about important developments that may affect how they decide to implement guideline
recommendations in their clinical practice.
What Are the Potential Benefits of This Project?
Ultimately, the aim of practice guidelines is to improve patient care. Guidelines
should help practicing psychiatrists determine what is known today about how best
to help their patients. In addition, psychiatrists and those charged with the allocation
of health care resources must try to make the best possible decisions on the basis
of currently available data. Well-developed guidelines can help in these efforts.
Toward the end of helping patients, guidelines can have other beneficial effects.
They are a vehicle for educating psychiatrists, other medical and mental health
professionals, and the general public about appropriate and inappropriate treatments.
By demonstrating that the quality of evidence for psychiatric treatments is on par
with (and in many cases exceeds) that for other medical care, guidelines contribute
to the credibility of the field. Guidelines identify those areas in which critical
information is lacking and in which research could be expected to improve clinical
decisions. Finally, guidelines can help those charged with overseeing the utilization
and reimbursement of psychiatric services to develop more scientifically based and
clinically sensitive criteria.
What Are the Possible Risks?
The APA reasons that the risks of this project are small and are considerably outweighed
by the benefits. One risk is that the guidelines can be misinterpreted and misused
by third parties in a way that will ultimately harm patients. Although this risk
rightfully concerns many psychiatrists, it is the judgment of the Steering Committee,
the Assembly, and the Board of Trustees that the existence of guidelines helps to
clarify the sources of disagreement between treating psychiatrists and reviewers
and that their use can be a great improvement over the use of criteria developed
through less objective procedures. In addition, many have expressed the concern
that guidelines can “homogenize” the care of patients and detract from
psychiatrists' freedom to shape treatment in ways that they feel best suit their
individual patients. Inevitably, there is a tension in writing guidelines between
the desire for specificity and the desire to allow for the consideration of individual
clinical circumstances. These concerns must be balanced in such a way that allows
psychiatrists to make appropriate clinical decisions. This very important issue
is addressed in the Statement of Intent
that begins each individually published guideline. Finally, there are concerns that
the APA-approved guidelines may lead to an increase in malpractice claims. At this
time, legal experts have mixed opinions about the impact of guidelines on the volume
and severity of malpractice suits. However, in fact, some medical specialties that
have been developing guidelines over the past two decades report that guidelines
seem to have had the positive effect of fewer claims and, for at least one specialty
(anesthesiology), lower malpractice insurance premiums. Since the publication of
APA's first practice guideline in 1993, the Steering Committee has been monitoring
the potential impact of the guidelines on malpractice actions and has not noted
any trends suggesting an increase in the number or severity of malpractice claims
that might be attributed to the existence of APA-approved guidelines.
How Can We Improve the Current Process?
Since the inception of the APA project in 1989, the practice guideline development
process has evolved significantly. Specifically, the activities of the work groups
developing the guidelines have been made more explicit, and the nature of the reviewers'
input has been standardized. Also, the format of each guideline has evolved over
the past several years. In guidelines developed after 1999, the recommendations
covering treatment, including the formulation of a treatment plan, are presented
before background information and the evidence that supports these recommendations.
This change in format was based on input from psychiatrists and is designed to make
the guidelines more user-friendly.
Certain principles remain crucial to further improvement. Clearly, practice guidelines
should be based on objective data whenever possible. Such data are of two types:
well-designed research studies and systematically identified clinical expertise.
Systematic reviews of the literature are an essential part of this work. However,
efforts to synthesize studies in any given area are hampered by the uneven quantity
and quality of research, by problems in generalizing from a literature largely derived
from tertiary care research settings to more typical clinical practice, by the inherent
difficulty in conducting controlled studies of some treatments for some populations,
and by the difficulty in characterizing “clinical consensus.” These
issues are being partially addressed through the use of the APA's Practice Research
Network (PRN), which uses a panel of approximately 800 psychiatrists in the full
range of practice settings to gather data for clinical research. Practice research
networks are also being used in other areas of medicine (e.g., family practice and
pediatrics) to gather data from practice settings of relevance to the development
of guidelines. For example, data about prevailing practice patterns and patient
outcomes can be systematically gathered and incorporated into the guidelines. In
addition, the impact of guidelines on psychiatric practice and patient outcomes
can be assessed; ultimately, it should be possible to determine whether guidelines
improve patient care. Currently, a major thrust of the APA project is to explore,
devise, and test educational and dissemination strategies that will increase psychiatrists'
use of the guidelines in daily practice.
Quick Reference Guides
In further attempts to increase the use and usefulness of the practice guidelines,
the APA now publishes with each guideline a quick reference guide (QRG). The QRG
is a summary of the guideline's major recommendations. The QRG is designed to assist
psychiatrists in using the material presented in the full-text guideline.
The idea to develop QRGs resulted from frequent comments by psychiatrists that the
length, text format, and comprehensive nature of APA's practice guidelines do not
allow for easy use in day-to-day work with patients. Since similar observations
have been made for guidelines in many fields of medicine, dissemination and implementation
strategies such as the QRGs have become the major foci of guideline projects, including
APA's.
The first APA QRG (on major depressive disorder) was developed in 1997 as part of
a study in conjunction with RAND Corporation and the New York State Psychiatric
Association, with grant support from the New York State Department of Health. The
response of psychiatrists using the QRG made clear that it was indeed a helpful
tool; thereafter, development of a QRG for each practice guideline became an important
component of the APA practice guidelines project.
The main challenge in developing a QRG is to present the major recommendations and
their sequencing in enough detail to be clinically helpful and at the same time
to limit the document to a usable length.
Central to proper use of these QRGs is recognition that they do not stand alone.
The psychiatrist using a QRG will find it helpful to return to the full-text practice
guideline for clarification of a recommendation or for a review of the evidence
supporting a particular strategy.
An essential feature of good guidelines is that they are revised at regular intervals
based on advances in the knowledge base and on input from guideline users. As APA
practice guidelines are revised, so will be their corresponding QRGs.
Online CME
Interactive continuing medical education programs for many of the individual practice
guidelines are available on the APA's web site (www.psych.org/cme).
Each program offers Category 1 CME credits that are accepted by the APA and the
American Medical Association.
The American Board of Psychiatry and Neurology (ABPN) has reviewed the APA Practice
Guidelines CME Program and has approved this product as part of a comprehensive
lifelong learning program, which is mandated by the American Board of Medical Specialties
as a necessary component of maintenance of certification.
ABPN approval is time limited to 3 years for each individual Practice Guideline
CME course. Refer to APA's CME web site for ABPN approval status of each course.
Conclusions
The practice guidelines represent an important step in the development of an “evidence-based
psychiatry.” The development of better research tools, the accumulation of
new research data, the systematic identification of best clinical practice, and
the iterative improvement of the process for developing practice guidelines will
contribute to the continual development of better practice guidelines to aid psychiatrists
in their clinical decision making.
Psychiatrists using the Practice Guidelines and Quick Reference Guides are encouraged
to submit suggestions for improvement of these tools. A feedback form is available
at http://mx.psych.org/survey/reviewform.cfm.
John S. McIntyre, M.D.
Chair, APA Steering Committee on Practice Guidelines
Sara C. Charles, M.D.
Vice-Chair, APA Steering Committee on Practice Guidelines
Laura J. Fochtmann, M.D.
Medical Editor, APA Practice Guidelines and Quick Reference Guides
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