About Clinical Practice Guidelines
Information to both the profession and the public on the expectations of the College on the use of clinical practice guidelines (CPGs)
What is a CPG?
CPGs are systematically developed and updated, evidence-based or consensus-based statements whose purpose is to help improve the quality and consistency of care in specified clinical situations.
CPGs synthesize large bodies of evidence, information and professional opinion into a form that is brief and as easily understandable as possible. They incorporate the most current evidence-based or consensus-based clinical information into a framework that promotes the best patient outcomes.
Typically, CPGs are intended to provide physicians with a framework for diagnosing, assessing and treating clinical conditions commonly encountered in practice.
Because CPGs are developed to promote best practice for populations of patients, they will have variable applicability to individual patients.
They do not define a standard of care, but may inform the standard of care.
CPGs do not establish inflexible protocols for patient care, nor are they meant to replace the professional judgment of physicians.
Many organizations develop CPGs, including speciality societies (e.g., Society of Obstetricians and Gynaecologists of Canada), associations that focus on patient advocacy for specific diseases/conditions (e.g., Canadian Diabetes Association), government, and other health care and medical organizations.
The development of CPGs should involve a standard and systematic process that adheres to specific criteria.1
The quality of available CPGs is variable; it depends on how well the guideline is developed.2
I: The Physician and CPGs
How should physicians use CPGs?
The College does not view CPGs as rules “cast in stone,” but rather as important resources, which will provide physicians with a range of appropriate options for patient care, based on available research data and professional consensus.
The College encourages physicians to use CPGs as one important tool for good patient care.
Physicians should consider CPGs as educational tools, combined with clinical judgment, to assist with the care of individuals or groups of patients.
Physicians should be aware of important existing CPGs relevant to their scope of practice, and should endeavour to keep abreast of any newly developed CPGs.
Since CPGs will not necessarily apply to all patients with a specific condition, patient care should reflect a physician’s knowledge of available CPGs.
Physicians are encouraged to take advantage of educational programs related to CPGs.3
II: The College and CPGs
How does the College use CPGs?
The College promotes the use of CPGs in practice by informing physicians of existing CPGs and directing physicians to the CMA infobase, the Guideline Advisory Committee (GAC) and other websites.
The College uses CPGs as educational tools. CPGs allow the College to establish a baseline of judgement to inform the performance assessment and physician education initiatives (including peer assessment and the review of patient complaints).
The following table summarizes the use of CPGs by four statutory committees of the College. Other committees may also incorporate CPGs into their decision-making process, as necessary.
College Committee Use of CPGs
Quality Assurance Committee
Peer Assessments: Used by both assessors and Quality Assurance Committee to inform the standard of care for practice evaluation.
Education: Used by assessors for education during the assessment process and may often form the basis of educational recommendations provided to physicians from the Quality Assurance Committee.
Review Panels: Used in the review panel process as the basis of discussions between review panel peer experts and physicians.
Executive Committee/Complaints Committee
Medical Inspections and Investigations: Used by medical inspectors, investigators and Complaints Committee to inform the standard of care.
Hearings: Panels of the Discipline Committee only review information introduced at a hearing. CPGs are not routinely used in disciplinary procedures unless they become part of the evidence at a hearing.
The College supports the production of well-developed CPGs. Pursuant to the direction of its Council, the College does not ordinarily develop CPGs.4 However, the College will consider developing CPGs if: the topic is consistent with the College’s priorities and goals; there is an immediate need to protect patient safety; and an appropriate CPG will not be developed by another organization.5
What will the College do if a physician does not follow CPGs?
CPGs can inform the exercise of sound clinical judgment. It is the position of the College that CPGs do not define a standard of care, but may inform a standard of care.
The College expects physicians to use CPGs as an educational resource, much as they would use any other educational resource (such as written materials about a diagnostic test or new knowledge obtained from a colleague).
The College accepts medically justified deviations from existing and widely used CPGs as demonstrations of clinical judgment and responsible approaches to good medical practice.
The College acknowledges that deviations from CPGs may be necessary for particular patients. These should be based on patient circumstances and the physician’s professional experience and judgment.
The College will consider all relevant circumstances in order to determine whether the physician exercised appropriate clinical judgment for a specific patient or group of patients.
The College views CPGs as a valuable component in a quality assurance-based approach to medical practice. Physicians are encouraged to incorporate recommendations from appropriate and well-developed CPGs into their practices. Decisions made by the College regarding the appropriateness of medical practice by physicians are based on the expectation that physicians will exercise sound clinical judgment, and make clinical decisions that are in keeping with that of their peers. Recommendations in appropriate CPGs constitute only one, albeit an important, measure in defining appropriate clinical care.
1 Systematic development for CPGs requires adherence to specific criteria including:
specification of the scope and purpose of the CPG (i.e., overall aim of CPG, specific clinical question, target population),
rigour of development (i.e., details of strategy used to search for evidence, criteria for including/excluding evidence specified, description of methods used to formulate recommendations, consideration of health benefits, side effects/risks of recommendations, and specified procedure for updates to CPG),
clarity and presentation,
applicability (i.e., organizational, behavioural and cost implications of CPG implementation) and,
2 The Guidelines Advisory Committee (GAC) was established by the Ontario Medical Association and the Ministry of Health and Long-Term Care. The GAC is one potential source of useful information on CPGs. The GAC assesses the rigour with which guidelines are developed.
3 The GAC offers workshops on the critical appraisal of guidelines.
4 In 2000, Council decided that the College would not operate a dedicated program to the development of CPGs, but would, in special circumstances, develop or facilitate the development of CPGs if warranted.
5 Examples of CPGs produced by the College include: EEG (2000), EMG (2001), Methadone Maintenance Guidelines (2001), and Evidence-Based Recommendations for the Medical Management of Chronic Non-Malignant Pain (2000).