Optometry’s North Star

Excerpted from page 28 of the November/December 2017 edition of AOA Focus.

In recent years, the production of a clinical practice guideline by the AOA's Evidence-Based Optometry (EBO) Committee for the National Guideline Clearinghouse (NGC) had taken its own rhythm.

The NGC, maintained by the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, is the self-described "go-to place" for clinical practice guidelines. Its mission is to not only collect a database of the evidence-based guidelines, but also to "further their dissemination, implementation, and use in order to inform health care decisions." The process of producing a guideline is time intensive—taking months to years—and meticulously methodical.

For instance, work on the AOA's evidence-based clinical practice guideline, Eye Care of the Patient with Diabetes Mellitus, began in May 2011. Once approved by the AOA Board of Trustees, the diabetes guideline took six months to be accepted by the NGC in July 2014.

Work began on the AOA's evidence-based clinical practice guideline, Comprehensive Adult Eye and Vision Examination, in June 2013. Acceptance by the NGC occurred in September 2016.

But when the Comprehensive Adult Eye and Vision Examination guideline was accepted to the NGC in June 2017, two days after it was submitted, Diane Adamczyk, O.D., chair of the EBO Committee, did a double take.

"The news that the NGC had accepted the pediatric guideline so quickly was remarkable," Dr. Adamczyk says. "Knowing that the NGC process takes time, I did have to pause and make sure I didn't misread this wonderful news."

On Nov. 7, 2017, in recognition of the Comprehensive Pediatric Eye and Vision Examination guideline's "significant contribution to the advancement of eye and vision care in the public health field," the American Public Health Association honored the AOA with its Outstanding Scientific Paper (Project) Award during its annual meeting in Atlanta, Georgia. It is the second AOA evidence-based guideline to receive this high honor.

Clinical guidelines 'we can trust'

Doctors of optometry rely on their training, knowledge, experience and patient input in deciding a course of treatment. Yet, clinical practice guidelines can contribute, too, in that decision-making.

First, guidelines can be a north star for doctors, helping guide them in providing the best care possible for patients. The NGC lists its influential audiences for the guidelines: individual physicians and clinicians; health care organizations and integrated delivery systems; medical specialty and professional societies; employers and other large purchasers; educational institutions; state and local governments. Add patients to the list—in an era when so many people get their health information online and feel empowered with that knowledge. The NGC is a dependable public resource.

Second, guidelines help make the case to regulatory, federal and state bodies that expanding the scope of practice of doctors of optometry is in the interest of public health.

At one time, clinical practice guidelines were more consensus-based than evidence-based.

That changed in 2011, when the Institutes of Medicine (now the National Academies of Sciences, Engineering and Medicine [NASEM]) sought to put more evidentiary information into the guidelines. It issued two transformative reports: Clinical Practice Guidelines We Can Trust and Finding What Works in Health Care: Standards for Systematic Reviews.

In Clinical Practice Guidelines We Can Trust, NASEM redefined clinical practice guidelines:

"Clinical practice guidelines are statements that include recommendations intended to optimize patient care that are informed by a systematic review of the evidence and an assessment of the benefits and harms of alternative care options."

There were eight standards published in the report that all guideline-writing groups have to follow and document, in order to be posted to the NGC:

1. Establish transparency. All guideline work has to be documented and transparent.
2. Manage conflict of interest. All groups/members must have documents on record.
3. Guideline development group composition. The group must be varied in practitioners, stakeholders/experts, and include a patient and patient advocate.
4. Guideline development group and systematic review. Writers should not be members of each other's teams.
5. Establish a process for grading strength of evidence and rating the strength of clinical recommendations prior to evaluating references, studies and supporting documents.
6. Articulation of clinical recommendations. The group must meet to review all the final evidence and articulate the best recommendations for practice.
7. External review process. All guidelines have to be posted for public and peer review and a process has to be established to collect all comments and record any action taken.
8. Establish 3- to 5-year update/review process. The second report, Finding What Works in Health Care: Standards for Systematic Reviews, determined the methodological standards for looking at research topics and systematically reviewing all materials to make a trustworthy clinical recommendation. Done correctly, systematic reviews should be included in any evidence-based guideline.

The EBO Committee's own protocol closely mirrors the NASEM process.

The advantages of this approach? Members of the EBO Committee say the process provides transparency; produces solid clinical recommendations based on the highest standards of research; expands the voices on the guideline development group (beyond doctors, there are patients and patient advocates); and standardizes processes such as literature searches.

"The guidelines are better because they're based on the best available science that is out there, which we look at critically," Dr. Adamczyk says. "That evidence-based approach is better for the profession and ultimately the care of the patient.

"They are meant to guide the practitioners on how they care for their patients," she says. "That's what we do. We take care of patients."

Of course, the NGC has its own rigorous standards for inclusion in its database of clinical practice guidelines. Among them are a systematic review and the backing of a relevant medical specialty association, a relevant professional society, government agency or a health care organization or plan.

The AOA currently has three guidelines on the NGC database website: Comprehensive Adult Eye and Vision Examination, Eye Care of the Patient with Diabetes Mellitus and Comprehensive Pediatric Eye and Vision Examination, making the AOA the only organization to have three guidelines listed in the database under optometry.

"They also have a very strict protocol," Dr. Adamczyk says, referring to the NGC. "To have your profession's clinical guideline accepted into the NCG means it has met a certain standard."

It takes a village—and time commitment

Serving on the EBO Committee takes a special kind of commitment, especially stick-to-it-iveness. Committee members say it also takes hard work, time, organization and passion.

"The volunteer time that goes into this is, in my mind, unparalleled," Dr. Adamczyk says.

For the committee, there is lots of reading, grading, absorbing, analyzing, evaluating, meeting, note-taking, calling, revising and collaborating but also robust clinical conversations, as one might expect from a diverse group of stakeholders around a table. During articulation meetings, for instance, group members hear summaries of several research articles and assess the evidence and study recommendations in perhaps hundreds of studies.

About 3,000 hours of volunteer time is given to each guideline—and that doesn't include the time of AOA staff­ or consultants.

"The passion comes out sometimes in the discussion," says Dr. Adamczyk with a smile. "But it's because people care so much. They are truly giving."

Meanwhile, the committee staff­ is tracking and documenting every detail, says Dr. Adamczyk, who praises their contributions. The NGC even specifies the format for submitting guidelines.

"This is a committee that works diligently," notes David Masihdas, O.D., who practices in Utah and is co-chair of the EBO Committee's guideline development group on diabetes.

All the while, they are working under a deadline.

So why volunteer, committing nights and weekends to the committee's work?

Dr. Masihdas' professional passion is the care of patients with diabetes, especially adolescents.

"Certainly, I'm educating myself," he says upon reflection. "My hope is that we are contributing to the profession."

Carl Urbanski, O.D., who practices in Pennsylvania, is co-chair of the AOA guideline development committee on glaucoma. The committee spent its first meeting narrowing the focus of its research to primary open-angle glaucoma, arriving at search terms for the hundreds of abstracts they will review, and deciding what questions their guidelines should answer.

Dr. Urbanski says the process will make him a better doctor. The hope, too, is that it will make other doctors better in order for patients to have better outcomes.

Says Dr. Urbanski: "I see a lot of glaucoma patients in my practice, and there are pathologies that interest me—macular degeneration, dry eye and glaucoma. So I really wanted to be involved with the EBO Committee. As a clinician, I'm not sure there is a better committee for me to be on to stay current with the topics that are part of my practice."

Munish Sharma, M.D., O.D., assistant professor at Western University of Health Science College of Optometry, calls the EBO Committee "family."

"Over the past couple of years, I've worked with members of the EBO committee like we are family, and just like family we work hard together, su­ffer losses and celebrate together each and every step in our shared professional and personal journeys," Dr. Sharma says.

Practice makes perfect?

The NGC requires that guidelines must be revised every three to five years, which will quicken the pace of the EBO Committee's work and necessitated the core EBO Committee to split into two guideline-development committees.

"This is the ­first time we've done two guidelines at the same time," Dr. Masihdas says.

The two guidelines currently in the committee pipeline are:

• A revision of the 2014 diabetes guideline, one of three guidelines produced by the   AOA under NASEM standards.
• A major rewrite of its 2010 glaucoma guideline that is currently a consensus document and must be brought up to the NASEM evidence standards.

The revised diabetes guideline is expected to be­ finished in late 2018; glaucoma in early 2019.

After the success of the pediatric vision clinical practice guideline, Dr. Adamczyk considers the notion that the upcoming guidelines will match that success. Only time will tell. The committee learns each time it produces a guideline, Dr. Adamczyk says.

"It's like making the honor roll," she says. "It's a special recognition."

"Being recognized by the NGC represents one of the highest levels of recognition in health care," Dr. Adamczyk says. "The members of the EBO Committee are passionate in their work and dedicate their time for the profession, and most importantly, for the care provided to our patients. Knowing the positive impact the guideline will have on the pediatric population and to all who will read it—from other health care professionals, pediatricians, teachers, parents and those interested in the eye care of children—fuels the dedication of the committee who understands the importance of their work."