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Podiatric Clinical Practice Guidelines: It’s Time for a Rewrite
Podiatric Clinical Practice Guidelines:
It’s Time for a Rewrite

In last week's Practice Perfect, I started to make the argument that our clinical practice guidelines in podiatry do not satisfy the purposes for which they were created. I identified the purpose and general characteristics of a practice guideline and proposed a basic method to evaluate them. This week, we let the rubber hits the road. Will our representative sample pass muster? Let’s see…

First, let me reiterate a point I made last week. I have great respect for those podiatric physicians who clearly took much time, effort, and leadership to create our guidelines. They should receive commendations for their excellent work, and the guidelines themselves have value and should be on all of our shelves. I will attempt to show that our guidelines, though well written and important, need to be rewritten to make them more evidence-based and more effective.

Ok. Let’s get to it.

I examined three published podiatric clinical practice guidelines, all three published in the Journal of Foot and Ankle Surgery:

  1. Forefoot Trauma Guidelines1
  2. Adult Flatfoot Guidelines2
  3. Diabetic Foot Disorders Guidelines3

For comparison, I also examined one non-podiatric guideline that pertains to the lower extremity:

  • Peripheral Arterial Disease Guidelines4

Using the checklist I presented last week, I evaluated each of the guidelines. Follow this link for the Appendix that shows the checklist results. According to my examination, the forefoot trauma and adult flatfoot guidelines almost completely failed to adequately satisfy the chosen criteria with a “Yes” answer in only 2 of 15 characteristics. The diabetic foot guidelines did a little better with 4 of 15 characteristics answered with a “Yes.” In comparison, the PAD guidelines satisfied 15 of 15 characteristics. All three podiatric guidelines failed to provide adequate information about the development group, formulate a stated consensus based on a systematic evaluation of the literature, or demonstrate appropriate peer review.

Please share your thoughts and concerns regarding Podiatric Clinical Practice Guidelines...

 

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References

1. Thomas J, et al. Diagnosis and Treatment of Forefoot Disorders. Section 5. Trauma. JFAS, Mar 2009; 48(2): 264-272.

2. Lee M, et al. Diagnosis and Treatment of Adult Flatfoot. JFAS, March 2005; 44(2): 78-113.

3. Frykberg R, et al. Diabetic Foot Disorders: A Clinical Practice Guideline (2006 Revision). JFAS, Sept 2006; 45 (5): S1-S66.

4. Olin J, et al. ACCF/AHA/ACR/SCAI/SIR/SVM/SVN/SVS 2010 Performance
Measures for Adults With Peripheral Artery Disease. Circulation, Dec 2010; 122: 2583-2618.

MEMBER COMMENTS
Re: Podiatric Clinical Practice Guidelines: It’s Time for a Rewrite

Most impressive as applied here, the checklist against the prior existing CPG's that is... But, my dear Doc Jarrod S., will you NOT consider also in your calculated new RE-writing of said 3 CPG's -and others to follow, to be sure- Dr. Groopman's hybrid "thinking and application of outside the box" necessity when and where it is necessary; and that would be:  the application of the proper treatment to the right patient at the right time for the right & proper indications NO MATTER the CPG's -based solely upon the Clinician's judgment of the case at hand AND the trajectory of the data, case, and MOST importantly = the PATIENT at hand.  We must BUILD that into our CPG's, lest we be "stuck" with -or- "stick" ourselves with a line diagram or algorithm that an HMO, pocket book, or any version of today's Palm Pilot would or could "dictate to us what we should or must do -OR- ONLY do!!

 ANyhoo, that's my 2 cents on the subject. 

Re: Podiatric Clinical Practice Guidelines: It’s Time for a Rewrite

I'll echo Dr. Godfrey's sentiment.  I love CPGs.  They're a fantastic starting point for a given treatment plan.  The problem is that we keep trying to make an exact science out of the art of medicine.  As long as the patients and doctors are human, there's a limit to how far cookbook medicine can take us.  Of course, insurance companies are NOT human, nor are legislators and a significant portion of the legal profession.

CPGs can take care of what happens 80% of the itme at least.  Beyond that, there is a long list of factors which can block off entire sections of an algorithm.  If a patient has no insurance and isn't willing or able to pay, exactly how are you going to get them to spring for the cost of an orthotic or Richie brace for PTTD?  Where does that fit into the flow chart?  Same for a patient's occasional irrational choice to not take oral medications.  What about doing extra things to satisfy an insurance company's guidelines before approving a test or treatment?  Defensive medicine?  The list goes on.

When listing the possible causes for a disease, very often you will see 'idiopathic'.  I tell my patients that it means "we know you have it, we just don't  know WHY".  A mirror image of sorts applies to diagnosing and treating conditions.  The standard treatment plan isn't working...we may or may know WHY it isn't working but, as Dr. Godfrey pointed out, we have to think outside the box and overcome the obstacles that exist to come up with something that works.

Treatment plan:  A, then B, then C, then D.

or: E.  None of the above.

 

Re: Podiatric Clinical Practice Guidelines: It’s Time for a Rewrite

Very thoughtful review of guidelines, Jarrod. To your points, the Diabetic Foot CPG was published in 2006 and developed initially in 2000. It is STILL the most extensively researched and comprehensive guideline for practice on the diabetic foot. Clinical Pathways were designed for clarity, but based on available evidence. We did not use grading sytems or levels of evidence to categorize evidence in that format, but did present a comprehensive review of most of the world's literature on the subject. At that time, it was not standard to  use a formal grading system for CPGs although they had started to come into use. Even the WHS guidelines by Steed et al in 2006 only presented Levels of evidence, not recommendation Grades. At this time, the GRADE system (BMJ | 26 April 2008 | Volume 336) for formulating guidelines is recommended- I do not recall that you mentioned this in your piece. Recommendations ("strong" and "weak") based on evaluation available evidence is far more useful than listing the quality evidence itself.

Although there were some shortcomings in the prior guidelines, their utility remains the same today and they are very frequently cited. Updates are always necessary and indeed, they should not follow your suggested criteria, but instead use the GRADE system for widespread utility. These are always works in progress.

Re: Re: Podiatric Clinical Practice Guidelines: It’s Time for a Rewrite
Quote:

Very thoughtful review of guidelines, Jarrod. To your points, the Diabetic Foot CPG was published in 2006 and developed initially in 2000. It is STILL the most extensively researched and comprehensive guideline for practice on the diabetic foot. Clinical Pathways were designed for clarity, but based on available evidence. We did not use grading sytems or levels of evidence to categorize evidence in that format, but did present a comprehensive review of most of the world's literature on the subject. At that time, it was not standard to  use a formal grading system for CPGs although they had started to come into use. Even the WHS guidelines by Steed et al in 2006 only presented Levels of evidence, not recommendation Grades. At this time, the GRADE system (BMJ | 26 April 2008 | Volume 336) for formulating guidelines is recommended- I do not recall that you mentioned this in your piece. Recommendations ("strong" and "weak") based on evaluation available evidence is far more useful than listing the quality evidence itself.

Although there were some shortcomings in the prior guidelines, their utility remains the same today and they are very frequently cited. Updates are always necessary and indeed, they should not follow your suggested criteria, but instead use the GRADE system for widespread utility. These are always works in progress.

 

Dr Frykberg. Thank you for your comments. You're clearly in the unique position to comment based on your involvement with the Diabetic Foot CPG. I couldn't agree more that the DM foot guidelines are still the best, as I mentioned in the editorial. I had a somewhat difficult time when I was writing the editorial because I didn't want to lump the guidelines you wrote with the ACFAS guidelines. Honestly, I've never seen a better review of a topic than these guidelines. You also make a very good point regarding the historical context in which the guidelines were written. Considering the fact that they are over a decade old and are still valid argues for their excellence!

But I believe your historical context also argues my point: that the guidelines need to be updated to include an evaluation of the quality of the research behind the guidelines. This is now a common method employed in the general medical profession as shown in the PAD guidelines. This is why I argued we should either rename these as Pathways or update the guidelines to conform with the rest of the medical profession.

You're correct that I didn't use the GRADE system when evaluating the various guidelines. Honesty must be maintained: I didn't know about this system until our discussion here, and I'm in the process of educating myself appropriately. That's the strength of this forum: another method to learn!

Perhaps adjusting the DM foot CPG to reflect this new paradigm would be appropriate?

I'd also like to respond to other interesting comments that were made primarily regarding the potential use of these guidelines against physicians. First, I don't think we should practice being afraid of the next lawsuit. As miserable as the prospect of being sued is we have an obligation to treat our patients to the best of our abilities using all available information to do so. Second, you could take that same argument to its extreme and say, "We should eliminate all guidelines completely so the lawyers wouldn't have anything to use against us." This is not a legitimate argument. If that were the case why do any research at all? If William Stewart Halstead were afraid of being sued we would still be doing surgery bare-handed and without gowns. Finally, I'd argue that a physician who follows high quality CPGs is more likely to treat patients successfully and is less likely to have complications. If you read the DM foot guidelines and actually listen to and use the recommendations you'll have a much more successful diabetic practice.

Submitted with the greatest respect.