Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
EDITORIAL
Use of clinical practice guidelines
Ben YF Fong, MPH(Syd), FHKAM (Community Medicine)
Division of Science, Engineering and Health Studies, College of Professional and Continuing Education, The Hong Kong Polytechnic
University, Hong Kong
Corresponding author: Dr Ben YF Fong (byffong@gmail.com)
In society, guidelines shape the behaviour and
steer the activities of people and organisations in
all aspects of daily routine. In the clinical setting,
professional care and services are often dictated by
clinical practice guidelines (CPGs) on topics from
screening, assessment, and diagnosis to management
of common and specific conditions. There are also
CPGs for unusual emerging pandemics: in the case
of coronavirus disease 2019 (COVID-19) the World
Health Organization has published extensive advice.1
According to the National Institute of Health
and Care Excellence of the United Kingdom, CPGs
contain evidence-based recommendations on the
ways healthcare professionals should care for people
with defined conditions. Such recommendations
are derived from the best available evidence. In
addition, CPGs are also of importance to health
services operators and managers as such guidelines
are essential for quality care.2
Effective CPGs are derived from evidencebased
medicine, and should be built on the best
available published research findings and experience
gained from clinical practice. To achieve the optimal
usage of CPGs, healthcare professionals should
understand the principles of development and
evaluation of the guideline. The AGREE II guidelines
and associated reporting checklist is considered
the international gold standard for developing and
evaluating CPGs.3 Quality, relevance, and strength
of the best available evidence are examined in detail
with a multidisciplinary approach when making
recommendations for clinical management. Ideally,
CPGs are embedded with flexibility and adaptability
to allow for a wide dissemination and adoption. In
addition, potential economic implications should
not be overlooked.4 Practically, CPGs should be
subject to regular structured evaluation and revision
to encompass the latest state-of-the-art of clinical
practice, new research evidence, current medical
advancement, and changed patient values.
Topics of CPGs are often selected on the basis
of priorities in quality improvement opportunities in
medical practice because physicians are expected to
provide their patients a certain standard of care. In a
review of CPGs, consensus statements, and position
statements from various specialties, the authors
found that to achieve the optimal benefits from
providing the best possible and quality care to the community, topics of CPGs should cover common
conditions that doctors encounter regularly.5
In this issue of the Hong Kong Medical Journal,
Chan et al from the Hong Kong College of Physicians,
representing sub-specialties in Cardiology,
Nephrology, Geriatric Medicine, Neurology and
Endocrinology, review two recent CPGs from
America and Europe on hypertension, both of which
have adopted a risk-based approach to treatment.6
On the basis of these guidelines, the authors have
developed a Position Statement on the classification
of blood pressure, measurement of blood pressure,
initiation of medications, treatment targets and
strategies, together with particular considerations
for geriatric, renal, and diabetic patients.6 In general,
the authors concur with the 2018 European Society
of Cardiology/European Society of Hypertension
guideline, and also note that the reviewed guidelines
have helped to improve public awareness of
hypertension and the importance of lifestyle changes
in managing hypertension.
Physicians use CPGs when making clinical
decisions, often with discussion with the patient
in some settings, about the appropriate care and
management of specific conditions or diseases.
Reviewing CPGs published in the Hong Kong
Medical Journal, some have provided guidance
on disease screening and prevention,7 8 whereas
others have offered a broad range of clinical
topics from management of common clinical
complaints to controversial issues based on the most
updated evidence.9 10 11 12 13 Guidelines include concise
recommendations and instructions for diagnosis,
tests, treatment options, drug therapy, management
algorithms that may direct the choice of medical,
and surgical or other clinical services.14 Because
CPGs are never perfect and evidence on their
effectiveness is incomplete,14 when making clinical
decisions, doctors also consider their experience
and knowledge through years of practice and
insights gained from the many cases encountered
and managed previously. Therefore, most doctors
have developed an individual approach to patient
management without consciously thinking about
CPGs. However, CPGs are useful when dealing with
uncommon conditions or diseases unfamiliar to
the practitioner, as well as in controversial clinical
situation. Under such circumstances, there is a high level of uncertainty as to the outcomes of clinical
courses being available or considered, such as the
current COVID-19 pandemic.
Adherence to CPGs in clinical practice is not
mandatory. However, the Medical Council of Hong
Kong has some guidelines to doctors in the Code
of Professional Conduct, “the little red book”, with
the intention to promote good clinical practice.15
There are guidelines on the proper prescription and
dispensing of dangerous drugs, ethics (covering
communication and dissemination of information
to the public and patients), adoption of new medical
procedures and human reproductive technology,
as well as on practice management including
signboards, service information notices, and doctors
directory. In addition, legal considerations are
practical issues when CPGs are not fully followed
or when treatment recommended in CPGs is not
offered to the patient. Following the advice found
in CPGs may provide a means of protection to
the doctor, as CPGs prescribe reasonable conduct
expected of medical practitioners who are also
expected to provide sufficient information to the
patient, particularly about risks involved in a clinical
decision.
Some CPGs contain definitive
recommendations whereas others are more
general, to allow for the clinical judgement of the
practitioner, and therefore carry a smaller risk of
liability. Generally, groups who develop CPGs, such
as members of a working group, are not usually held
liable for the application of CPGs. Furthermore, use
of CPGs as evidence in court depends on how the
guidelines are developed and whether they are up
to date. Good CPGs should have a strong research
evidence base, should have undergone independent
review, should have built-in flexibility for adoption
in different clinical situation, and should carry an
expiry date.4 Practitioners should have adequate
understanding of the salient points in CPGs to fully
exploit the guidelines in clinical settings.
The purpose of CPGs is to improve the health
and condition of patients, not only as individuals but
also as members of the community, particularly when
society is facing escalating costs of health services
and medical technologies, ageing populations,
increasing demands and expectations of users,
inconsistent service quality of providers, and even
inappropriate care. Use of CPGs by physicians in
clinical practice can lead to more structured and
consistent decisions and care delivery in a more
objective manner, supported by the embedded
evidence. The Primary Healthcare Office of the Hong
Kong SAR Government has published four reference
frameworks on disease management of hypertension
and diabetes, and on preventive care for children and
elderly patients. The frameworks aim to facilitate
family doctors to provide continuing comprehensive and evidence-based care in the community.16 In the
code of practice to private hospitals and clinics,
the Department of Health demands that these
institutions comply with guidelines and standards
issued by professional and government bodies, and
that CPGs must be easily accessible and available to
staff for their reference.17
Doctors should use appropriate CPGs in their
daily practice for the benefit and better quality of
life of their patients. However, CPGs must not be
regarded as the absolute consensus recommendations
with answers to all clinical situations. Intrinsic
shortcomings in the development of guidelines are
not uncommon. Patients are not all the same; they
vary in personal characteristics and responses to
treatments. Moreover, doctors differ in their clinical
judgement. Use of CPGs by physicians is still very
much the core of medicine, being both an art and a
science.
Author contributions
The author contributed to the editorial, approved the final version for publication, and takes responsibility for its
accuracy and integrity.
Conflicts of interest
The author has disclosed no conflicts of interest.
References
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