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The year
2003 marks 12 years since ASA embarked on the development
of evidence-based practice parameters. These parameters
have been an essential part of a national effort by
ASA to enhance the safety and quality of anesthetic
practice. An evidence-based approach to the development
of practice parameters grew out of the recognition
that many aspects of clinical care are complex and
cannot be fully addressed without rigorous attention
to available scientific and clinical evidence. Therefore,
practice guidelines were initially developed to assist
the practitioner and the patient in making beneficial
decisions about anesthesia care. Practice guidelines
were found to be flexible enough to accommodate the
complexities of clinical practice and contained evidence
derived from a rigorous evaluation of scientific literature
as well as expert opinion. In 1997, practice advisories
were added to the repertoire of evidence-based practice
parameters.
Since 1993, 11 guidelines have been approved and published
by ASA, including guidelines for management of the
difficult airway, pulmonary artery catheterization,
acute pain management in the perioperative setting,
blood component therapy, cancer pain management, chronic
pain management, perioperative transesophageal echocardiography,
sedation and analgesia by nonanesthesiologists, obstetrical
anesthesia, preoperative fasting and postanesthetic
care. In addition, two practice advisories have been
published on prevention of perioperative peripheral
neuropathies and preanesthesia evaluation. All of
these documents are subject to periodic updates; current
updates for sedation and analgesia, difficult airway
management and pulmonary artery catheterization have
been completed and approved.
ASA seeks evidence from a broad variety of sources,
including scientific studies, clinical literature,
expert and consultant opinion and practitioner commentary.
For a typical practice parameter, evidence is derived
from the evaluation of 3,000 to 5,000 published articles
and the synthesis of three to five surveys of consultant
opinion. The analytic approach is highly rigorous
and usually involves meta-analysis, assessment of
implementation costs, statistical measures of agreement
and tests of homogeneity, inter-rater reliability,
publication bias and feasibility. These tasks are
conducted by a methodology unit composed of two health
service analysts and a research librarian.
Evidence-based practice parameters also are strongly
rooted in consensus formation. A proactive approach
to consensus formation is particularly useful because
it accelerates the acceptance and application of these
documents throughout the practicing community. ASA
regards diversity of background and experience as
important prerequisites for consensus formation. A
task force of eight to 10 anesthesiologists leads
each practice parameter project. Its members are chosen
carefully to provide a balance between private practice
and academia as well as representation from each of
the major geographic areas of the United States. Each
task force, in turn, identifies approximately 75 to
100 consultants who serve as an additional source
of opinion, practical knowledge and expertise. The
consultant group is similarly balanced for practice
setting and geographic location. The consultant group’s
diversity helps to ensure a broad perspective and
good “reality testing.”
Once the evidence has been transformed into a draft
document, an open forum is held in conjunction with
a national meeting. During the forum, the draft is
read aloud, and the audience provides line-by-line
commentary. All remarks are recorded carefully and
later analyzed. Often open forums result in substantial
and important refinements. As an extension of the
open forum process, drafts are distributed to consultants
and a wide selection of local and national leaders
of ASA. Final acceptance by ASA requires an independent
committee review, an open hearing and approval by
the House of Delegates, the main governmental body
of ASA.
Practice parameter topics under development include
a practice guideline on perioperative management of
pacemakers and other cardiac devices and updates of
practice guidelines for acute pain in the perioperative
setting, blood component therapy and obstetrical anesthesia.
In addition, a practice advisory for perioperative
blindness is planned. Also under consideration is
a guideline for the anesthetic management of patients
with obstructive sleep apnea.
The need for the guideline on pacemakers and implantable
cardioverter defibrillator (ICD) devices was made
more urgent by the publication of the American College
of Cardiology/American Heart Association Guideline
Update on Perioperative Cardiovascular Evaluation
for Noncardiac Surgery. A section of this report makes
recommendations about pacemakers and ICDs, which we
believe many physicians and institutions will be unable
to carry out.
The American Medical Association Practice Parameter
Partnership strongly recommends that every guideline
be revised or sunsetted every five years. If the guideline
is not updated every five years, it will be dropped
from the Web site of the National Guideline Clearinghouse,
sponsored by the Agency for Healthcare Research and
Quality, which can be found at <www.guideline.gov>.
This Web site contains the most comprehensive list
of clinical practice guidelines and is considered
to be the authoritative source.
The ASA Committee on Practice Parameters has let the
five-year period slide for two major reasons. One
is cost and the second is that the revision initiative
would need to be undertaken at about three and a half
years to assure publication at the five-year deadline.
This issue will continue to be evaluated carefully.
ASA owes a great debt of gratitude to all of you who
have participated in the process.
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James F. Arens, M.D., is Professor and Chair,
Department of Anesthesiology, M.D. Anderson
Cancer Center, Houston, Texas. He was ASA President
in 1989. |
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