Quality and consistency of clinical practice guidelines for diagnosis and management of osteoarthritis of the hip and knee: a descriptive overview of published guidelines

Osteoarthritis (OA) is a degenerative joint disease and is one of the 10 most disabling diseases in developed countries.1 Self-report data suggest that 15% of Australians have arthritis, and much of this burden is OA.2 A major cause of pain, disability and use of health care resources among middle-aged and older people, the costs associated with ongoing care of patients with OA in terms of medications, days lost from work, and cost of long-term care facilities are high.3 There is no known cure for OA, but there is an abundance of evidence available to guide diagnosis and management, and many clinical practice guidelines (CPGs) exist at the local, national and international level.

The use of evidence-based CPGs to inform clinical practice is increasing throughout the world.4 Evidence-based CPGs have the potential to improve the quality of health care by promoting interventions of proven benefit and discouraging unnecessary, ineffective or harmful interventions.5 CPG developers are encouraged to employ evidence-based principles6,7 and undertake consultation with relevant stakeholders, and peer review, dissemination and implementation, and review and updating of the resultant CPG.6,7 CPG development groups should include consumer representatives as well as relevant clinical and methodological experts. The comprehensive nature of this process means that developing evidence-based CPGs can take time and be costly.

Despite this, national and international organisations are increasingly developing their own CPGs, potentially leading to multiple CPGs on the same topic, which may not be consistent in their recommendations or quality.7 Duplication of CPGs within the same clinical area has been demonstrated in type 2 diabetes,8 acute low back pain9 and lower-limb OA,10-12 where the recommendations are consistent among CPGs, but the evidence underpinning these recommendations varies.8 Methodological quality of CPGs is found to vary considerably. Overall quality and transparency of CPG development processes, and consistency in reporting is poor.9-12 While there have been descriptive overviews of CPGs for OA of the hip and/or knee, these reviews have not performed comprehensive searches and therefore only contain a subset of available relevant CPGs, and often conclude with a call for more CPGs.

Here, we present a comprehensive descriptive overview and critical appraisal of CPGs for diagnosis and management of OA of the hip and/or knee identified through a comprehensive search. We aim to encourage future CPG development approaches in OA (such as adapting existing CPGs) that consider the time- and resource-intensive nature of this process.

This descriptive overview of CPGs for OA was conducted within a larger study evaluating a collaborative method to promote best practice in management of OA of the hip and/or knee in Victorian general practices.13 One outcome of this larger study was a key messages table (available at http://www.cochrane.org.au/projects/osteo_guidelines.php) that comprised a summary of CPG recommendations. This project was funded by a grant from the Australian Government Arthritis and Musculoskeletal Quality Improvement Program.

Our search yielded a total of 291 potentially relevant articles. Of these, 193 were retrieved from databases and 98 from websites that specifically publish CPGs. Of the 291 potentially relevant articles, 242 were excluded after screening the titles and abstracts, leaving 49 to be assessed based on the full text version of the article. Of those 49 articles, 34 CPGs were identified for management of OA of the hip and/or knee and were included in this overview (Box 2).

Of the 34 CPGs included in our overview, 17 originated from the United States, seven from the United Kingdom, four from Europe, two each from Australia and Canada, and one each from South Africa and Hong Kong; their publication dates ranged from 1993 to 2005. There was a marked increase in the number of CPGs developed since 2000 (28 CPGs), with most being published in the UK and US. Fourteen CPGs were newly developed, three were adapted from existing CPGs, and eight were updates of existing CPGs. In the case of nine of the CPGs, it was unclear whether they were newly developed, adapted or updated.

CPGs varied considerably in format, coverage and scope. For example, some CPGs provided detailed information about indicators for diagnosis, while other CPGs were limited to a brief list of indicators only. Similarly, the scope varied, with some CPGs being limited to a specific management modality (pharmacological management) while others included more than one or all possible management modalities (pharmacological, nonpharmacological and surgery). Irrespective of the organisation that developed the CPG, population, coverage or scope, most CPGs had similar recommendations for aspects of diagnosis and treatment of OA of the hip and/or knee.

There is substantial investment in the development and dissemination of CPGs to inform clinical practice and promote effective health care.4 Multiple CPGs on the same topic are being developed by various local, national and international organisations, and these CPGs are not necessarily consistent in either their recommendations or their quality.7 Where recommendations are consistent, the duplication of effort is time- and resource-intensive and potentially wasteful; where inconsistent, they can provide conflicting treatment recommendations.23 Ideally, the quality of CPGs, as assessed by a validated framework, should be consistent across CPGs regardless of topic or setting.

Our overview describes the number and content of CPGs for the diagnosis and management of OA of the hip and/or knee at the local, national and international level. Treatment recommendations included in these CPGs are consistent, but only a small number of the CPGs included were adapted from existing CPGs — most were newly developed.

Given the consistency among recommendations in existing CPGs, and the time-intensive and resource-intensive nature of CPG development, a possible approach for future guidance in this setting is the adaptation of existing high-quality CPGs to local contexts. This could form one step in an overall implementation strategy to ensure sustainable quality of care for patients with OA. Adaptating CPGs to local contexts, facilitated by key local knowledge translation experts who have experience in applying evidence to a local setting, also has the potential to lead to better uptake of CPGs. Adaptation of CPGs should be systematic and transparent, should involve stakeholders, and should report the key factors that influence decisions, including those in the original CPG, and the reasons for any modifications that are made.24 Steps often lacking in the original development process, such as piloting of CPGs among target users, patient input and review, auditing, external review, consideration of organisational barriers, cost implications and updating plans can be addressed in the adaptation process.

An example of a framework for identifying CPGs for local adaptation is ADAPTE.25 ADAPTE is useful for determining whether to adapt an existing CPG by means of a step-by-step process that promotes the use of evidence-based and rigorous development principles, and introduces concepts for adapting CPGs from their original setting to different contexts, whether cultural or organisational.25 Adaptation of CPGs is addressed in varying levels of detail in handbooks for preparing CPGs from the Council of Europe, the National Health and Medical Research Council (Australia), the National Institute for Clinical Excellence (UK), the New Zealand Guidelines Group and the Scottish Intercollegiate Guidelines Network.26

There have been cases where high-quality CPGs have been adapted to the local context and implemented successfully into clinical practice. One such model is the Australian-based Health for Kids (HFK) project that is designed to improve health care for children through best practice and partnerships among medical, nursing and allied health clinicians and consumers.27 The HFK model involves key local CPG development specialists adapting existing high-quality CPGs for local use, and has been implemented in the care of asthma and diarrhoea.28

In this overview, we have shown an example of a large number of CPGs addressing the same clinical issue. These CPGs were of varying quality, but consistent in the recommendations given. Given the time and resources required for evidence-based CPG development, we encourage future developers to first determine whether a high-quality evidence-based CPG already exists for the clinical topic of interest, and then to assess whether the CPG is suitable for adaptation to the local context. If a high-quality evidence-based CPG exists, it may be unnecessary to duplicate a search of the primary research and instead focus on adapting existing CPGs and addressing the poor uptake of CPGs by designing well funded and rigorous implementation and sustainability strategies for practices known to be effective, and facilitating research to address identified areas lacking evidence.