APA Practice Guidelines: Introduction


Why Is the APA Developing Practice Guidelines?

How Are APA Practice Guidelines Developed?

What Have Been the Benefits of APA Practice Guidelines?

Have There Been Disadvantages of APA Practice Guidelines?

Conclusions

References



Joel Yager , M.D.
Chair, APA Steering Committee on Practice Guidelines

James E. Nininger, M.D.
Vice-Chair, APA Steering Committee on Practice Guidelines

Laura J. Fochtmann, M.D.
Medical Editor, APA Practice Guidelines


Practice guidelines are systematically developed patient care strategies intended to assist physicians in clinical decision making. The American Psychiatric Association (APA) began developing evidence-based practice guidelines for the treatment of psychiatric disorders in 1989. The development process was designed to have attributes recommended by the American Medical Association (1996), including transparency and explicitness, and to result in guidelines with desirable scientific qualities described by the Institute of Medicine (1990, 1992) including validity, reproducibility, and clarity.

The first evidence-based APA practice guideline developed under this process, on eating disorders, was published in 1993. APA guidelines now available on PsychiatryOnline address fourteen different mental disorders or topics and include many second and third editions, such as the third edition guideline on major depressive disorder published in 2010. Each guideline is accompanied by a quick reference guide. For many guidelines, a continuing medical education (CME) course is also available at APA’s website for CME and lifelong learning, www.apaeducation.org. Some guidelines also have an associated “watch” describing major developments in the scientific literature since original guideline publication. Watches are different than guidelines in that they represent opinion of the authors rather than official policy of the APA.

Readers should note that these documents are indeed “guidelines” and are not intended to be “standards of care.” As described in a Statement of Intent, APA guidelines do not necessarily include all proper methods of care for a particular patient. 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.

Why Is the APA Developing Practice Guidelines?

APA's primary aim in developing practice guidelines is to assist psychiatrists in their clinical decision making, with the ultimate goal of improving the care of patients. Like all physicians, psychiatrists are challenged to keep up with the explosion of research-based knowledge in our field. It has been estimated that medical advances, even those demonstrated by randomized controlled trials, can take 15-20 years to be adopted into routine patient care (Balas and Boren 2000, Institute of Medicine 2001). For busy clinicians, guidelines provide a convenient review and synthesis of a vast number of study findings.Guidelines also give clear statements about which treatments are supported by evidence or expert opinion and which require further research. Guidelines are also useful policy documents. Systematically developed guidelines and performance measures derived from these guidelines may be used both to improve healthcare quality by promoting effective interventions and to discourage the use of inappropriate or ineffective interventions (Institute of Medicine 2001, 2008). Physicians have expressed concern that performance measures may not be clinically meaningful or may have unintended consequences, such as reducing patient satisfaction or incentivizing physicians to avoid difficult-to-treat patients (Weyer et al. 2008, Bozic et al. 2007). Nevertheless, performance measurement appears to be an inevitable trend, and measures for psychiatry are now being developed by managed care organizations, health care systems, government agencies, and others including the American Medical Association’s Physician Consortium for Performance Improvement. To ensure that such measures are acceptable to psychiatrists, APA has advocated that measures on psychiatric treatments should be based on APA practice guidelines rather than other sources.

How Are APA Practice Guidelines Developed?

APA guidelines published from 1993 to 2010 have been developed under the direction of the Steering Committee on Practice Guidelines using an essentially consistent process described here. This process has included the following elements: appointment of an expert work group who are APA members; adherence to disclosure and conflict of interest policies intended to minimize bias from competing interests, especially from industry relationships; systematic review of available evidence including creation of evidence tables; broad, iterative review of drafts by other experts, the APA membership, and stakeholders including allied organizations and patient and family advocacy groups; final approval of guidelines by the APA Assembly and Board of Trustees; and regular review and revision. Development of the guidelines is funded solely by APA, which as an organization derives revenues from member dues, educational activities, and publications. No direct industry or commercial funding for APA guideline development has ever been accepted.

In 2011, at the request of the U.S. Congress, the Institute of Medicine published companion reports recommending standards for the development of “trustworthy” clinical practice guidelines and for the development of systematic reviews of evidence that inform guidelines (Institute of Medicine 2011a, 2011b). In response to these reports, APA’s Steering Committee on Practice Guidelines has begun to pilot changes to APA’s guideline development process. These include ensuring multidisciplinary expertise on guideline work groups; organizing guidelines around focused clinical questions rather than broad categories of illness; obtaining input on the questions from patient and family representatives; using independent raters to screen literature search results; and using the GRADE system (Guyatt et al. 2011) to separately rate recommendations according to strength of recommendation and strength of supporting evidence

In addition to these changes that are intended to address the Institute of Medicine standards, the Steering Committee is piloting other technical and process innovations intended to further improve the quality of APA guidelines, make them more user friendly, and facilitate our efforts to keep them up to date. These innovations include use of formal surveys of large panels of clinical and research experts to assess expert consensus around potential recommendations; use of a modified Delphi method to determine consensus of work groups; use of medical informatics principles to streamline screening of literature search results; formatting guidelines as modules to facilitate their integration into electronic media including electronic health records; and use of standing work groups to continuously review new evidence and update recommendations on an as needed basis. Some of these innovations are being funded by a medical informatics grant from the National Library of Medicine that was awarded in 2010.

Guidelines on psychiatric evaluation and management are now being developed using the pilot process described above. Publication is anticipated in 2013.

What Have Been the Benefits of APA Practice Guidelines?

In addition to improving patient care, APA guidelines have been used to educate psychiatrists, other physicians, mental health professionals, and the general public about evidence-based psychiatric treatments. They have also contributed to the credibility of the field by demonstrating the ever-increasing quality of evidence for psychiatric treatments, at levels meeting or exceeding the quality of evidence for treatments of other medical specialties. The guidelines also identify gaps in critical information where additional research is needed. Finally, as described above, good guidelines provide a scientific and clinically sensitive basis for decision-making by policymakers and resource regulators.

Have There Been Disadvantages of APA Practice Guidelines?

APA has reasoned that the benefits of developing practice guidelines far outweigh the disadvantages. However, some APA members have asked whether guidelines have created medicolegal difficulties for psychiatrists or limited psychiatrists' flexibility in meeting the treatment needs and preferences of individual patients.

Guidelines are just that—guidelines. As described in the Statement of Intent, APA guidelines must be applied and interpreted in the context of individual patient circumstances. Indeed, evidence-based practice has been defined "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research" (Sackett 1996).

Despite this, it is possible for guidelines to be misinterpreted or misused by third parties, such as insurers or regulatory agencies, in ways that might constrain care and ultimately harm patients. Although this risk is understandably of concern, it is less likely to occur with APA guidelines than with guidelines developed outside the profession, especially guidelines specifically developed to control healthcare costs or guidelines developed without rigorous review of available evidence or consideration of clinical consensus about best practices.

The medicolegal impact of APA practice guidelines has not been studied in detail. Legal experts have mixed opinions about the impact of guidelines on the volume of malpractice suits and the magnitude of compensation to plaintifs. Some medical specialties report that guidelines seem to have reduced malpractice claims, and at least one specialty (anesthesiology) has noted lower malpractice insurance premiums (personal communciation, Professional Risk Management Services, Inc. [PRMS]). Since the publication of APA's first practice guideline in 1993, the Steering Committee has been monitoring the potential medicolegal impact of the guidelines. No trends have been observed that would suggest either an increase or decrease in the number of malpractice claims (personal communication, PRMS).

Conclusions

Practice guidelines represent an important step in enhancing the evidence-based practice of psychiatry. Guideline development itself is also evolving into a more evidence-based field. Methodologies such as those proposed by the GRADE Working Group and the recommendations of the Institute of Medicine are important scholarly advances. APA will continue to explore and test these proposals and our own innovations, with the goal of producing guidelines that are as good, authoritative, and carefully considered as we can expect to achieve in an imperfect world.

Psychiatrists who use APA 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.

References

American Medical Association. Attributes to Guide the Development and Evaluation of Practice Parameters/Guidelines. Chicago: Author, 1996.

Balas EA, Boren SA. Managing clinical knowledge for health care improvement. In: Bemmel J, McCray AT (eds), Yearbook of Medical Informatics 2000: Patient-Centered Systems. Stuttgart, Germany: Schattauer Verlagsgesellschaft mbH; 2000:65-70.

Bozic KJ, Smith AR, Mauerhan DR. Pay-for-performance in orthopedics: implications for clinical practice. J Arthroplasty. 2007 Sep;22(6 Suppl 2):8-12.

Guyatt G, Oxman AD, Akl EA, Kunz R, Vist G, Brozek J, Norris S, Falck-Ytter Y, Glasziou P, DeBeer H, Jaeschke R, Rind D, Meerpohl J, Dahm P, Schünemann HJ.

GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. J Clin Epidemiol. 2011 Apr;64(4):383-94.

Institute of Medicine. Clinical Practice Guidelines: Directions for a New Program. Washington, DC: National Academy Press, 1990.

Institute of Medicine. Guidelines for Clinical Practice: From Development to Use. Washington, DC: National Academy Press, 1992.

Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press, 2001.

Institute of Medicine. Knowing What Works in Health Care: A Roadmap for the Nation. Washington, DC: National Academy Press, 2008.

Institute of Medicine. Finding What Works in Health Care: Standards for Systematic Reviews. Washington, DC: National Academy Press, 2011b.

Sackett, D. Evidence-based Medicine—What it is and what it isn't. BMJ 1996; 312:71-72. Available at http://www.bmj.com/cgi/content/full/312/7023/71.