Decomposing clinical practice guidelines panels' deliberation into decision theoretical constructs.

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Clinical Guidelines
Authored By
Djulbegovic B, Hozo I, Lizarraga D, Guyatt G
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Internal/Family Medicine
Hematology
Speciality
Hematology
Internal/Family Medicine
Book Detail
volume
29
ISSN
1365-2753
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1365-2753
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["Djulbegovic B, Hozo I, Lizarraga D, Guyatt G","Publisher: Wiley-Blackwell Country of Publication: England NLM ID: 9609066 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1365-2753 (Electronic) Linking ISSN: 13561294 NLM ISO Abbreviation: J Eval Clin Pract Subsets: MEDLINE","Journal Article; Research Support, U.S. Gov't, P.H.S.; Research Support, Non-U.S. Gov't","2023-04-01","Journal of evaluation in clinical practice [J Eval Clin Pract] 2023 Apr; Vol. 29 (3), pp. 459-471. Date of Electronic Publication: 2023 Jan 24.","English","1365-2753","Pulmonary Embolism*, Humans ; Probability ; Clinical Decision-Making","Humans, Probability, Clinical Decision-Making, Pulmonary Embolism","Journal of evaluation in clinical practice","29"]
Description
RATIONALE, AIMS AND OBJECTIVES: The development of clinical practice guidelines (CPG) suffers from the lack of an explicit and transparent framework for synthesising the key elements necessary to formulate practice recommendations. We matched deliberations of the American Society of Haematology (ASH) CPG panel for the management of pulmonary embolism (PE) with the corresponding decision-theoretical constructs to assess agreement of the panel recommendations with explicit decision modelling.<br />Methods: Five constructs were identified of which three were used to reformulate the panel's recommendations: (1) standard, expected utility threshold (EUT) decision model; (2) acceptable regret threshold model (ARg) to determine the frequency of tolerable false negative (FN) or false positive (FP) recommendations, and (3) fast-and-frugal tree (FFT) decision trees to formulate the entire strategy for management of PE. We compared four management strategies: withhold testing versus d-dimer → computerized pulmonary angiography (CTPA) ('ASH-Low') versus CTPA→ d-dimer ('ASH-High') versus treat without testing.<br />Results: Different models generated different recommendations. For example, according to EUT, testing should be withheld for prior probability PE &lt; 0.13%, a clinically untenable threshold which is up to 15 times (2/0.13) below the ASH guidelines threshold of ruling out PE (at post probability of PE ≤ 2%). Three models only agreed that the 'ASH low' strategy should be used for the range of pretest probabilities of PE between 0.13% and 13.27% and that the 'ASH high' management should be employed in a narrow range of the prior PE probabilities between 90.85% and 93.07%. For all other prior probabilities of PE, choosing one model did not ensure coherence with other models.<br />Conclusions: CPG panels rely on various decision-theoretical strategies to develop its recommendations. Decomposing CPG panels' deliberation can provide insights if the panels' deliberation retains a necessary coherence in developing guidelines. CPG recommendations often do not agree with the EUT decision analysis, widely used in medical decision-making modelling.<br /> (© 2023 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons Ltd.)
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