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Seeking ‘meta guidelines’ for lipids

‘Metacognition’ is defined as the ‘awareness and understanding of one’s own thought processes’. Perhaps we all need to develop such a ‘meta approach’ to deal with the ongoing release of new national and international lipid guidelines. Guidelines represent an important touchstone for the management of individual patients, for secondary prevention and for population strategies, usually for primary prevention. Why are clinical practice guidelines important? Both patients and practitioners presume that guidelines crystallize the outcome of a sound scientific process that utilized standardized protocols to grade and evaluate evidence, typically randomized controlled trials (RCTs) and meta-analyses of these. Guidelines can influence standards of care and inform regulatory policies. Financial reimbursement may depend on achieving prespecified guideline-defined targets. Once they become the de facto standard of care, guidelines are used in peer review assessments and malpractice claims. Mehta et al. reported a strong ‘dose-response’ association between adherence to guidelines and performance measures and outcomes. But why do different recommendations seem to arise from various guidelines, especially as the same evidence supposedly forms the basis for each? The problem intensifies as clinicians feel inundated with different guidelines, especially when some present seemingly conflicting messages. It is beyond the scope of this editorial to compare and contrast all the different guidelines; however, the process of guideline development and the terms of reference are important determinants in the final recommendations. In an attempt to standardize guideline development, the US Institute of Medicine (IOM) suggested the following guiding principles: (1) establish transparency; (2) manage conflict of interest; (3) describe guideline development group composition; (4) clarify clinical practice guidelines/systematic review intersection; (5) establish evidence foundations for rating the strength of recommendations; (6) articulate recommendations; (7) define external review; and (8) establish a process for updating. The American College of Cardiology/ American Heart Association (ACC/AHA) 2013 guidelines articulated such guiding principles, and groups such as a Mayo Clinic task force were able to offer constructive criticisms. Some of these criticisms included the concern that medical truth is more than the sum of only randomized trials (i.e. ‘scientific proof’), and excluding non-statin lipid-lowering therapies since there was no proof (‘the lack of evidence of benefit does not equal evidence of no benefit’). An expert writing committee of the ACC/AHA, in reaction to these concerns, recommended measurement of an initial and follow-up lipid panel to gauge desired treatment efficacy, with the option that non-statin drugs ‘may be considered’ to reduce low-density lipoprotein (LDL) cholesterol. One of us (RAH) was a contributing author for the recent Canadian Cardiovascular Society (CCS) lipid guidelines, and can verify that this process endeavoured to adhere to all IOM principles. A somewhat novel feature of the 2016 CCS guidelines was utilizing population, intervention, comparator, outcomes (PICO) questions posed by the primary panel. The PICO format helps clinicians determine whether the recommendations apply to patients in their practice. A sample PICO question is: ‘Among adults in whom screening is recommended is non-fasting lipid determination equivalent to fasting lipid determination for risk assessment?’ The guidelines discuss and evaluate the evidence and provide recommendations in the context of this question and answer format. The process involved review of articles published since the previous 2013 CCS guidelines, an initial face-to-face meeting of the primary writing panel, regular teleconferences and frequent emails between subcommittee members. Each recommendation required ratification by a 2/3 blinded and anonymous vote, and 90% of them were accepted.