September 2022
Surgeons, particularly cardiothoracic surgeons are defined by technical excellence and our high standards for delivery of complex patient care. We dedicate years of our lives training for excellence, analyzing our own outcomes, continually practicing, improving, and striving for better ways to deliver care to our patients. Our commitment to delivering the best state-of-the-art care in an era when medical knowledge is doubling every few months, new devices are rapidly being evaluated through corporate-sponsored clinical trials, and many cardiothoracic patients receive some aspect of their care via other specialists, establishes the critical need for highly vetted clinical practice guidelines. It is vitally important that surgeons active in the field analytically evaluate, challenge, and establish recommendations when controversies or variations in practice exist. This is most important when applicable, high quality, randomized prospective data are non-existent or of limited scope.
Five years ago, the STS and AATS published a joint position statement on the development of clinical practice documents based on the landmark Institute of Medicine report “Clinical Practice Guidelines We Can Trust” published in 2011.1,2 This critical AATS/STS manuscript set the standards for the creation of joint cardiothoracic clinical practice guidelines (CPGs) and expert consensus documents (ECDs) that have become so important in our field. The creation of impactful, useful documents requires thorough and unbiased critical review of the available literature. Data interpretation must be done by a diverse group of experts in the field, with metrics and outcomes that reflect long-term success in a specific patient population. This manuscript highlighted that expertise for CPG and ECD participation needs to include not only the management of the cardiovascular or thoracic disease under review but also knowledge pertinent to guideline structure, quality assessment, and creation of practical recommendations. Representative diversity is key, since consensus among a broad diverse group of practicing physicians and surgeons with different experiences and patient populations is far more likely to be correct than consensus among a small group of like-minded participants.
Recently, the STS and AATS have been working together to assure that cardiothoracic surgical practice is adequately represented in establishing guidelines that impact the care of cardiothoracic patients and the practice of our specialty. Our recent discussions and support from the European Association for Cardio-Thoracic Surgery (EACTS) and European Society of Thoracic Surgeons (ESTS) have made our voice even stronger. Several projects whereby AATS and STS are working together to jointly endorse CPGs as well as intersocietal support for respective ECDs are underway. It is critical that we continue to be unified in our actions to assure adequate surgical representation on guidelines and in the processes that lead to their creation and acceptance. Surgical participation is about having input into the questions being asked, the definition of success, and the process by which these key aspects are determined. To assure representation of surgical practice standards, we need to support our surgical representatives on the various guideline committees and assure that they are active participants with voice into the selection and vetting of studies, interpretation of data and the definition of meaningful metrics of success or complications. It has become clear that cardiothoracic surgeons must become involved in, and highly knowledgeable about, the entire process of guideline and consensus statement development.
To this end, the leadership of the AATS, STS, EACTS, and ESTS are jointly developing a course/webinar(s) to educate cardiothoracic surgeons on the creation of guidelines and the differences between CPGs and EGDs. The course is divided into three sections. The first section examines topic selection, writing group composition, evidence synthesis and appraisal, and how these impact the decision of whether a CPG, EGD, or expert opinion/white paper is appropriate. The second section will focus on identifying and mitigating conflict of interest and bias (inherent and occupational), understanding the power of group dynamics, role of societal communication, conflict management, and identifying misinterpretation or extrapolation of data into new areas. The last section will explore the clinical, medicolegal, and financial implications of these documents on individual surgeons and cardiothoracic practice. Case studies of successes and challenges in guideline development will be used throughout the course to highlight these concepts.
This course will be a primer for societal representatives on guideline committees and thus it will be important to communicate with your societies when you are asked to join a writing group. Ultimately, it is our goal for all cardiothoracic surgeons to know and understand the strengths and weaknesses of CPGs and ECDs and the enormous benefits and potential harms to patient care and our specialty that can arise if these guidelines are not accurate. The more educated we can become as a specialty, the more likely we are to have a voice in the decisions that impact our future and the needs of our cardiothoracic surgical patients. I hope you will join us in the future to learn more about the process behind CPGs and ECDs and become more engaged in helping to define the best long-term care solutions for all of our patients.
- Bakaeen FG, Svensson LG, Mitchell JD, Keshavjee S, Patterson GA, Weisel RD. The American Association for Thoracic Surgery/ Society of Thoracic Surgeons Position Statement on Developing Clinical Practice Documents. J Thorac Cardiovasc Surg 2017;153:999-1005 and Ann Thorac Surg 2017;103:1350–6.
- https://nap.nationalacademies....
Yolonda L. Colson, MD
AATS 103rd President