Keith B. Holten, MD, Editor

• What are the best methods to assess delirium and acute problematic behavior in the long-term care setting?
• What is the most appropriate treatment for these patients?
• Why is monitoring of interventions critical to patient outcomes?

The answers to these questions are summarized at right and in the 2008 edition of Delirium and Acute Problematic Behavior in the Long-Term Care Setting, published by the American Medical Directors Association (AMDA). This comprehensive guideline, developed to improve quality of care, features a 15-step systematic approach to recognizing, assessing, treating, and monitoring long-term care patients with delirium and acute problematic behavior. It includes a simple algorithm to guide the decision-making process.

Initially developed to fill a gap

Delirium and acute problematic behavior are common in the long-term care setting, but management guidelines have been limited. To assist physicians, advanced practice nurses, nurses, and allied health professionals in long-term care facilities, the AMDA developed the initial version of this guideline in 1998. A multidisciplinary workgroup used a process that combined evidence- and consensus-based approaches: An electronic literature search identified pertinent guidelines, research articles, and review articles, and the recommendations were based on the opinions of the expert workgroup.

Guideline revision expands its scope

The guideline update was completed in 2008, under the direction of the AMDA Clinical Practice Guideline Steering Committee. The new version incorporates information published in peer-reviewed journals after the original guideline was released; it has also been expanded to incorporate recommendations from seasoned practitioners in long-term care.

The AMDA facilitated peer review of the revised guideline, with input from 175 individuals outside of the steering committee. The result is a well-written, practical guide to dealing with long-term care residents with altered mental states.

A few limitations

This guideline does not include grades for individual recommendations. Since the recommendations are based on expert opinion, the evidence is rated C using the SORT taxonomy.¹ The recommendations are easy to understand, but an executive summary would have been useful. The algorithm lacks detail, which weakens its clinical value.

In addition, this 36-page guideline is available only in print from the AMDA. Lack of Internet access limits its accessibility at the point of care.

Source for this guideline

American Medical Directors Association (AMDA). Delirium and acute problematic behavior in the long-term care setting. Columbia, Md: American Medical Directors Association (AMDA); 2008. 36 p. (36 references). Available from the American Medical Directors Association. (http://www.amda.com/tools/cpg/alteredmentalstates.cfm).

Other guideline on this topic

American Psychiatric Association. Practice guideline for the treatment of patients with delirium. American Psychiatric Association. Am J Psychiatry. 1999 May;156(5 suppl):S1-S20. [135 references]. Guideline Watch. August 2004. Available at: www.psychiatryonline.com/pracGuide/pracGuideChapToc_2.aspx.

The APA guideline is not current. The major recommendations focus on psychiatric management, environmental and supportive interventions, and somatic interventions. Although the guideline is based on a systematic review of the literature, the APA does not describe the methods used to review the evidence. Nor does it report ratings for the level of evidence.

CORRESPONDENCE Keith B. Holten, MD, 825 Locust Street, Wilmington, OH 45177; [email protected]

• What are the best methods to assess delirium and acute problematic behavior in the long-term care setting?
• What is the most appropriate treatment for these patients?
• Why is monitoring of interventions critical to patient outcomes?

The answers to these questions are summarized at right and in the 2008 edition of Delirium and Acute Problematic Behavior in the Long-Term Care Setting, published by the American Medical Directors Association (AMDA). This comprehensive guideline, developed to improve quality of care, features a 15-step systematic approach to recognizing, assessing, treating, and monitoring long-term care patients with delirium and acute problematic behavior. It includes a simple algorithm to guide the decision-making process.

Initially developed to fill a gap

Delirium and acute problematic behavior are common in the long-term care setting, but management guidelines have been limited. To assist physicians, advanced practice nurses, nurses, and allied health professionals in long-term care facilities, the AMDA developed the initial version of this guideline in 1998. A multidisciplinary workgroup used a process that combined evidence- and consensus-based approaches: An electronic literature search identified pertinent guidelines, research articles, and review articles, and the recommendations were based on the opinions of the expert workgroup.

Guideline revision expands its scope

The guideline update was completed in 2008, under the direction of the AMDA Clinical Practice Guideline Steering Committee. The new version incorporates information published in peer-reviewed journals after the original guideline was released; it has also been expanded to incorporate recommendations from seasoned practitioners in long-term care.

The AMDA facilitated peer review of the revised guideline, with input from 175 individuals outside of the steering committee. The result is a well-written, practical guide to dealing with long-term care residents with altered mental states.

A few limitations

This guideline does not include grades for individual recommendations. Since the recommendations are based on expert opinion, the evidence is rated C using the SORT taxonomy.¹ The recommendations are easy to understand, but an executive summary would have been useful. The algorithm lacks detail, which weakens its clinical value.

In addition, this 36-page guideline is available only in print from the AMDA. Lack of Internet access limits its accessibility at the point of care.

Source for this guideline

American Medical Directors Association (AMDA). Delirium and acute problematic behavior in the long-term care setting. Columbia, Md: American Medical Directors Association (AMDA); 2008. 36 p. (36 references). Available from the American Medical Directors Association. (http://www.amda.com/tools/cpg/alteredmentalstates.cfm).

Other guideline on this topic

American Psychiatric Association. Practice guideline for the treatment of patients with delirium. American Psychiatric Association. Am J Psychiatry. 1999 May;156(5 suppl):S1-S20. [135 references]. Guideline Watch. August 2004. Available at: www.psychiatryonline.com/pracGuide/pracGuideChapToc_2.aspx.

The APA guideline is not current. The major recommendations focus on psychiatric management, environmental and supportive interventions, and somatic interventions. Although the guideline is based on a systematic review of the literature, the APA does not describe the methods used to review the evidence. Nor does it report ratings for the level of evidence.

CORRESPONDENCE Keith B. Holten, MD, 825 Locust Street, Wilmington, OH 45177; [email protected]

• What are the best methods to assess delirium and acute problematic behavior in the long-term care setting?
• What is the most appropriate treatment for these patients?
• Why is monitoring of interventions critical to patient outcomes?

The answers to these questions are summarized at right and in the 2008 edition of Delirium and Acute Problematic Behavior in the Long-Term Care Setting, published by the American Medical Directors Association (AMDA). This comprehensive guideline, developed to improve quality of care, features a 15-step systematic approach to recognizing, assessing, treating, and monitoring long-term care patients with delirium and acute problematic behavior. It includes a simple algorithm to guide the decision-making process.

Initially developed to fill a gap

Delirium and acute problematic behavior are common in the long-term care setting, but management guidelines have been limited. To assist physicians, advanced practice nurses, nurses, and allied health professionals in long-term care facilities, the AMDA developed the initial version of this guideline in 1998. A multidisciplinary workgroup used a process that combined evidence- and consensus-based approaches: An electronic literature search identified pertinent guidelines, research articles, and review articles, and the recommendations were based on the opinions of the expert workgroup.

Guideline revision expands its scope

The guideline update was completed in 2008, under the direction of the AMDA Clinical Practice Guideline Steering Committee. The new version incorporates information published in peer-reviewed journals after the original guideline was released; it has also been expanded to incorporate recommendations from seasoned practitioners in long-term care.

The AMDA facilitated peer review of the revised guideline, with input from 175 individuals outside of the steering committee. The result is a well-written, practical guide to dealing with long-term care residents with altered mental states.

A few limitations

This guideline does not include grades for individual recommendations. Since the recommendations are based on expert opinion, the evidence is rated C using the SORT taxonomy.¹ The recommendations are easy to understand, but an executive summary would have been useful. The algorithm lacks detail, which weakens its clinical value.

In addition, this 36-page guideline is available only in print from the AMDA. Lack of Internet access limits its accessibility at the point of care.

Source for this guideline

American Medical Directors Association (AMDA). Delirium and acute problematic behavior in the long-term care setting. Columbia, Md: American Medical Directors Association (AMDA); 2008. 36 p. (36 references). Available from the American Medical Directors Association. (http://www.amda.com/tools/cpg/alteredmentalstates.cfm).

Other guideline on this topic

American Psychiatric Association. Practice guideline for the treatment of patients with delirium. American Psychiatric Association. Am J Psychiatry. 1999 May;156(5 suppl):S1-S20. [135 references]. Guideline Watch. August 2004. Available at: www.psychiatryonline.com/pracGuide/pracGuideChapToc_2.aspx.

The APA guideline is not current. The major recommendations focus on psychiatric management, environmental and supportive interventions, and somatic interventions. Although the guideline is based on a systematic review of the literature, the APA does not describe the methods used to review the evidence. Nor does it report ratings for the level of evidence.

CORRESPONDENCE Keith B. Holten, MD, 825 Locust Street, Wilmington, OH 45177; [email protected]

• What are the critical steps in assessing a patient with chronic pain?
• What are the 4 biological mechanisms of pain?
• When is referral to a pain specialist recommended?

The answers to these questions are summarized at right and in the 2008 edition of Assessment and Management of Chronic Pain. Originally developed in 2005, the guideline was funded and published by the Institute for Clinical Systems Improvement (ICSI), a collaboration of 57 medical groups sponsored by 6 Minnesota health plans. A 3rd edition, released in August, summarizes the current evidence in the assessment and treatment of chronic pain in mature adolescents (ages 16-18 years) and adults.

Chronic pain—a persistent, life-altering condition—is one of the most challenging clinical disorders for primary care physicians to treat. Unlike acute pain, where we seek to cure the underlying biological condition, the goal of chronic pain management is to improve patient function in the face of pain that may never completely resolve.

Achieving that goal, according to the new guideline, requires a patient-centered, multifaceted approach—often involving a health care team that includes specialists in behavioral health and physical rehabilitation—that is co-ordinated by a primary care physician. An effective treatment plan must address biopsychosocial factors as well as spiritual and cultural issues. Patients must be taught self-management skills focused on fitness, stress reduction, and maintaining a healthy lifestyle ( TABLE ). Medications may be part of the treatment plan but should not be the sole focus, according to the guideline. Opioids are an option when other therapies fail.

ICSI’s new guideline also addresses the effects of various therapies, the role of psychosocial factors, and the identification of barriers to treatment. The comprehensive guideline, which has 172 references and 9 appendices, also features 2 easy-to-use algorithms. One algorithm addresses the assessment of chronic pain ( FIGURE 1 ) and the other deals with chronic pain management ( FIGURE 2 ). Both algorithms identify level I and level II strategies. And both can be readily adapted to primary care practice, and are extremely helpful to physicians who are evaluating and developing care plans for patients with chronic pain.

FIGURE 1
Chronic pain assessment algorithm

4 objectives

This latest guideline was developed to:

• Improve the treatment of adult chronic pain patients by encouraging physicians to complete an appropriate biopsychosocial assessment (and reassessment).
• Improve patient function by recommending the development and use of a comprehensive treatment plan that includes a multispecialty team.
• Improve the use of Level I and Level II treatment approaches to chronic pain.
• Provide guidance on the most effective use of nonopioid and opioid medications in the treatment of chronic pain.

With these objectives in mind, the ICSI work group conducted a comprehensive literature review, giving priority to randomized controlled trials (RCTs), meta-analyses, and systematic reviews. The work group used a 7-tier grading system to rate the evidence and a 3-category system for the worksheets in the appendix. For this article, we have converted the evidence ratings into SORT taxonomy.¹

What’s changed?

In addition to reflecting the latest research, the new guideline contains a number of clarifications. For example, the update states that medications are not the “sole” focus of treatment and should be used, when necessary, as part of an overall approach to pain management. The previous version noted that medications were not the “primary” focus.

The management algorithm ( FIGURE 2 ) now leads with “core principles”—a term suggesting greater importance than the former term, “general management,” implied. Clinical highlights, a synthesis of key recommendations, have been revised to better align with the guideline’s main components—assessment, functional goals, patient-centered/biopsychosocial care planning, Level I vs Level II approaches, and medication and patient selection.

Other changes in the guideline may contribute to clinicians’ understanding of chronic pain and its complex presentation. The guideline now includes a statement about allodynia and hyperalgesia to indicate that both may play an important role in any pain syndrome—not just complex regional pain syndrome. Information about fibromyalgia symptoms and myofascial pain has been added. The definitions page now has an entry for “biopsychosocial model,” as well as language designed to stress the differences between untreated acute pain and ongoing chronic pain.

FIGURE 2
Chronic pain management algorithm 

A limitation, an improvement

A limitation of the guideline is the lack of studies addressing the effectiveness of a comprehensive, multidisciplinary treatment approach to chronic pain management. Most studies consider single therapies.

An improvement in this guideline is that the evidence levels of each strategy are now listed within the section describing it—a notable change that makes it far easier to identify the quality of individual recommendations.

As has been the case in the past, this latest edition of the guideline offers a number of tools for physicians. The assessment and management algorithms ( FIGURES 1 AND 2 , respectively) walk clinicians through the decision-making process. In addition, the following 9 appendices provide practical guidance to physicians in various aspects of patient evaluation and care:

• Brief Pain Inventory (Short Form)
• Patient Health Questionnaire (PHQ-9)
• Functional Ability Questionnaire
• Personal Care Plan for Chronic Pain
• DIRE (diagnosis, intractability, risk, efficacy) Score: Patient Selection for Chronic Opioid Analgesia
• Opioid Agreement Form
• Opioid Analgesics
• Pharmaceutical Interventions for Neuropathic Pain
• Neuropathic Pain Treatment Diagram.

Source for this guideline

Institute for Clinical Systems Improvement (ICSI). Assessment and Management of Chronic Pain. 3rd ed. Bloomington (Minn): Institute for Clinical Systems Improvement (ICSI); 2008 July. Available at: http://www.icsi.org/pain__chronic__assessment_and_management_of_14399/pain__chronic__assessment_and_management_of__guideline.html. Accessed September 9, 2008.

• What are the critical steps in assessing a patient with chronic pain?
• What are the 4 biological mechanisms of pain?
• When is referral to a pain specialist recommended?

The answers to these questions are summarized at right and in the 2008 edition of Assessment and Management of Chronic Pain. Originally developed in 2005, the guideline was funded and published by the Institute for Clinical Systems Improvement (ICSI), a collaboration of 57 medical groups sponsored by 6 Minnesota health plans. A 3rd edition, released in August, summarizes the current evidence in the assessment and treatment of chronic pain in mature adolescents (ages 16-18 years) and adults.

Chronic pain—a persistent, life-altering condition—is one of the most challenging clinical disorders for primary care physicians to treat. Unlike acute pain, where we seek to cure the underlying biological condition, the goal of chronic pain management is to improve patient function in the face of pain that may never completely resolve.

Achieving that goal, according to the new guideline, requires a patient-centered, multifaceted approach—often involving a health care team that includes specialists in behavioral health and physical rehabilitation—that is co-ordinated by a primary care physician. An effective treatment plan must address biopsychosocial factors as well as spiritual and cultural issues. Patients must be taught self-management skills focused on fitness, stress reduction, and maintaining a healthy lifestyle ( TABLE ). Medications may be part of the treatment plan but should not be the sole focus, according to the guideline. Opioids are an option when other therapies fail.

ICSI’s new guideline also addresses the effects of various therapies, the role of psychosocial factors, and the identification of barriers to treatment. The comprehensive guideline, which has 172 references and 9 appendices, also features 2 easy-to-use algorithms. One algorithm addresses the assessment of chronic pain ( FIGURE 1 ) and the other deals with chronic pain management ( FIGURE 2 ). Both algorithms identify level I and level II strategies. And both can be readily adapted to primary care practice, and are extremely helpful to physicians who are evaluating and developing care plans for patients with chronic pain.

FIGURE 1
Chronic pain assessment algorithm

4 objectives

This latest guideline was developed to:

• Improve the treatment of adult chronic pain patients by encouraging physicians to complete an appropriate biopsychosocial assessment (and reassessment).
• Improve patient function by recommending the development and use of a comprehensive treatment plan that includes a multispecialty team.
• Improve the use of Level I and Level II treatment approaches to chronic pain.
• Provide guidance on the most effective use of nonopioid and opioid medications in the treatment of chronic pain.

With these objectives in mind, the ICSI work group conducted a comprehensive literature review, giving priority to randomized controlled trials (RCTs), meta-analyses, and systematic reviews. The work group used a 7-tier grading system to rate the evidence and a 3-category system for the worksheets in the appendix. For this article, we have converted the evidence ratings into SORT taxonomy.¹

What’s changed?

In addition to reflecting the latest research, the new guideline contains a number of clarifications. For example, the update states that medications are not the “sole” focus of treatment and should be used, when necessary, as part of an overall approach to pain management. The previous version noted that medications were not the “primary” focus.

The management algorithm ( FIGURE 2 ) now leads with “core principles”—a term suggesting greater importance than the former term, “general management,” implied. Clinical highlights, a synthesis of key recommendations, have been revised to better align with the guideline’s main components—assessment, functional goals, patient-centered/biopsychosocial care planning, Level I vs Level II approaches, and medication and patient selection.

Other changes in the guideline may contribute to clinicians’ understanding of chronic pain and its complex presentation. The guideline now includes a statement about allodynia and hyperalgesia to indicate that both may play an important role in any pain syndrome—not just complex regional pain syndrome. Information about fibromyalgia symptoms and myofascial pain has been added. The definitions page now has an entry for “biopsychosocial model,” as well as language designed to stress the differences between untreated acute pain and ongoing chronic pain.

FIGURE 2
Chronic pain management algorithm 

A limitation, an improvement

A limitation of the guideline is the lack of studies addressing the effectiveness of a comprehensive, multidisciplinary treatment approach to chronic pain management. Most studies consider single therapies.

An improvement in this guideline is that the evidence levels of each strategy are now listed within the section describing it—a notable change that makes it far easier to identify the quality of individual recommendations.

As has been the case in the past, this latest edition of the guideline offers a number of tools for physicians. The assessment and management algorithms ( FIGURES 1 AND 2 , respectively) walk clinicians through the decision-making process. In addition, the following 9 appendices provide practical guidance to physicians in various aspects of patient evaluation and care:

• Brief Pain Inventory (Short Form)
• Patient Health Questionnaire (PHQ-9)
• Functional Ability Questionnaire
• Personal Care Plan for Chronic Pain
• DIRE (diagnosis, intractability, risk, efficacy) Score: Patient Selection for Chronic Opioid Analgesia
• Opioid Agreement Form
• Opioid Analgesics
• Pharmaceutical Interventions for Neuropathic Pain
• Neuropathic Pain Treatment Diagram.

Source for this guideline

Institute for Clinical Systems Improvement (ICSI). Assessment and Management of Chronic Pain. 3rd ed. Bloomington (Minn): Institute for Clinical Systems Improvement (ICSI); 2008 July. Available at: http://www.icsi.org/pain__chronic__assessment_and_management_of_14399/pain__chronic__assessment_and_management_of__guideline.html. Accessed September 9, 2008.

• What are the critical steps in assessing a patient with chronic pain?
• What are the 4 biological mechanisms of pain?
• When is referral to a pain specialist recommended?

The answers to these questions are summarized at right and in the 2008 edition of Assessment and Management of Chronic Pain. Originally developed in 2005, the guideline was funded and published by the Institute for Clinical Systems Improvement (ICSI), a collaboration of 57 medical groups sponsored by 6 Minnesota health plans. A 3rd edition, released in August, summarizes the current evidence in the assessment and treatment of chronic pain in mature adolescents (ages 16-18 years) and adults.

Chronic pain—a persistent, life-altering condition—is one of the most challenging clinical disorders for primary care physicians to treat. Unlike acute pain, where we seek to cure the underlying biological condition, the goal of chronic pain management is to improve patient function in the face of pain that may never completely resolve.

Achieving that goal, according to the new guideline, requires a patient-centered, multifaceted approach—often involving a health care team that includes specialists in behavioral health and physical rehabilitation—that is co-ordinated by a primary care physician. An effective treatment plan must address biopsychosocial factors as well as spiritual and cultural issues. Patients must be taught self-management skills focused on fitness, stress reduction, and maintaining a healthy lifestyle ( TABLE ). Medications may be part of the treatment plan but should not be the sole focus, according to the guideline. Opioids are an option when other therapies fail.

ICSI’s new guideline also addresses the effects of various therapies, the role of psychosocial factors, and the identification of barriers to treatment. The comprehensive guideline, which has 172 references and 9 appendices, also features 2 easy-to-use algorithms. One algorithm addresses the assessment of chronic pain ( FIGURE 1 ) and the other deals with chronic pain management ( FIGURE 2 ). Both algorithms identify level I and level II strategies. And both can be readily adapted to primary care practice, and are extremely helpful to physicians who are evaluating and developing care plans for patients with chronic pain.

FIGURE 1
Chronic pain assessment algorithm

4 objectives

This latest guideline was developed to:

• Improve the treatment of adult chronic pain patients by encouraging physicians to complete an appropriate biopsychosocial assessment (and reassessment).
• Improve patient function by recommending the development and use of a comprehensive treatment plan that includes a multispecialty team.
• Improve the use of Level I and Level II treatment approaches to chronic pain.
• Provide guidance on the most effective use of nonopioid and opioid medications in the treatment of chronic pain.

With these objectives in mind, the ICSI work group conducted a comprehensive literature review, giving priority to randomized controlled trials (RCTs), meta-analyses, and systematic reviews. The work group used a 7-tier grading system to rate the evidence and a 3-category system for the worksheets in the appendix. For this article, we have converted the evidence ratings into SORT taxonomy.¹

What’s changed?

In addition to reflecting the latest research, the new guideline contains a number of clarifications. For example, the update states that medications are not the “sole” focus of treatment and should be used, when necessary, as part of an overall approach to pain management. The previous version noted that medications were not the “primary” focus.

The management algorithm ( FIGURE 2 ) now leads with “core principles”—a term suggesting greater importance than the former term, “general management,” implied. Clinical highlights, a synthesis of key recommendations, have been revised to better align with the guideline’s main components—assessment, functional goals, patient-centered/biopsychosocial care planning, Level I vs Level II approaches, and medication and patient selection.

Other changes in the guideline may contribute to clinicians’ understanding of chronic pain and its complex presentation. The guideline now includes a statement about allodynia and hyperalgesia to indicate that both may play an important role in any pain syndrome—not just complex regional pain syndrome. Information about fibromyalgia symptoms and myofascial pain has been added. The definitions page now has an entry for “biopsychosocial model,” as well as language designed to stress the differences between untreated acute pain and ongoing chronic pain.

FIGURE 2
Chronic pain management algorithm 

A limitation, an improvement

A limitation of the guideline is the lack of studies addressing the effectiveness of a comprehensive, multidisciplinary treatment approach to chronic pain management. Most studies consider single therapies.

An improvement in this guideline is that the evidence levels of each strategy are now listed within the section describing it—a notable change that makes it far easier to identify the quality of individual recommendations.

As has been the case in the past, this latest edition of the guideline offers a number of tools for physicians. The assessment and management algorithms ( FIGURES 1 AND 2 , respectively) walk clinicians through the decision-making process. In addition, the following 9 appendices provide practical guidance to physicians in various aspects of patient evaluation and care:

• Brief Pain Inventory (Short Form)
• Patient Health Questionnaire (PHQ-9)
• Functional Ability Questionnaire
• Personal Care Plan for Chronic Pain
• DIRE (diagnosis, intractability, risk, efficacy) Score: Patient Selection for Chronic Opioid Analgesia
• Opioid Agreement Form
• Opioid Analgesics
• Pharmaceutical Interventions for Neuropathic Pain
• Neuropathic Pain Treatment Diagram.

Source for this guideline

Institute for Clinical Systems Improvement (ICSI). Assessment and Management of Chronic Pain. 3rd ed. Bloomington (Minn): Institute for Clinical Systems Improvement (ICSI); 2008 July. Available at: http://www.icsi.org/pain__chronic__assessment_and_management_of_14399/pain__chronic__assessment_and_management_of__guideline.html. Accessed September 9, 2008.

When is outpatient treatment appropriate for community-acquired pneumonia (CAP)? Which antibiotics are recommended for outpatient therapy? What are the best prevention strategies? The answers are in the consensus guidelines published earlier this year by the Infectious Diseases Society of America and the American Thoracic Society (IDSA/ATS). The new guidelines update an IDSA guideline published in 2003.

Background. Management (and prevention) of CAP is inconsistent, and there is also emerging resistance of pneumococcus to macrolides.

These guidelines were developed to hasten consistency among caregivers and hospitals in the care of patients with pneumonia. Appropriateness of outpatient care, severity of illness assessment, hospital treatment decisions, ICU care, and choice of antibiotics for high-risk patients and for drug-resistant S pneumonia were reviewed. The joint committee recommended that hospitals standardize care and create policies to increase the vaccination rate.

Cases that test your skills

CASE 1

Your patient is a 45-year-old man with cough, fever, and chills. He has a history of metabolic syndrome, and a 40 pack-year smoking history. He was well until 1 week ago when he went camping in the rain. Over the last 2 days he has had shaking chills, cough productive of green phlegm, and he finds that he gets a bit short-winded when walking stairs. He wonders if he has pneumonia. He is overweight and in no acute distress.

T 101 • P 88 • RR 18 • WT 220 • HT 5 7

Exam Normal other than localized coarse rales in the left posterior lung field; spot O₂ saturation is 96%

What is your diagnosis and initial management?

Which of the following statements are true regarding the outpatient management of pneumonia?

1. If 2 or more CURB-65 criteria are present, the patient should be hospitalized
2. A macrolide is an appropriate choice of treatment for a previously healthy person with no risk of drug resistance
3. A positive chest x-ray or other imaging is required for the diagnosis
4. Blood cultures and sputum cultures must be obtained
5. Antibiotic treatment should be a minimum of 10 days

ANSWERS: A, B, AND C

Diagnosis Community acquired pneumonia—left lobar.

Initial management This patient can be treated as an outpatient based on the severity-of-illness scores in this guideline. He should be treated with antibiotics a minimum of 5 days. With his comorbidities, antibiotic choices include 1) a fluoroquinolone, 2) a beta-lactam plus macrolide, or 3) (in areas with high prevalence of macrolide resistance) a beta-lactam plus doxycycline.

CASE 2

A 76-year-old man is brought into the office by his niece. “I just don’t feel well,” he says. The patient has been increasingly ill over the past week, and his niece is concerned that he seems to have trouble breathing. The patient minimizes his symptoms, but in relaying his history, he is obviously short of breath and cannot talk continuously. He needed a wheelchair to come in from the parking lot (and you know that he is usually spry and ambulatory). He has a history of congestive heart failure, hypertension, type 2 diabetes mellitus, depression, and osteoarthritis. He takes furosemide, potassium, enalapril, lantus insulin, sertraline, and PRN acetaminophen. He has never smoked. He denies PND and orthopnea. He is clearly short of breath and in some mild distress.

T 99 • P 102 • RR 36 • WT 260 • HT 5 9

Exam Remarkable for diffuse rhonchi and wheezing across all lung fields; spot O₂ saturation is 89%

What is your diagnosis and initial management?

The differential diagnosis for this patient includes:

1. Bacterial pneumonia
2. Viral pneumonia
3. Depression
4. Congestive heart failure
5. Pulmonary embolus

ANSWERS: A, B, D, E

Diagnosis This interstitial pattern on the chest x-ray is associated with multiple etiologies, both infectious and non-infectious. Examples include viral pneumonia, opportunistic infections in HIV patients, atypical infections such as mycoplasm, congestive heart failure, and pulmonary embolus.

Initial management Based on severity-of-illness scores, this patient should be admitted to the hospital. He should have further evaluation to identify the etiology.

By definition, CAP is acquired outside a hospital or long-term care facility. However, the new guidelines include ambulatory residents of nursing homes.

Adults with CAP are the focus of the guidelines, not immunocompromised patients, cancer patients receiving chemotherapy, patients on high-dose steroid therapy, or children under 18 years.

Epidemiology. There are about 5.6 million cases of CAP in the United States annually, and the cost is about $8.4 billion.¹ Death rates increase with comorbidities and older age. There are no race or gender differences in morbidity.

Limitations of the guidelines. The decision whether to admit a patient with CAP is crucial, since the majority of the pneumonia care expenditures are the result of in-patient care.² The guidelines do not state the outcomes that were considered or adverse events associated with therapy. It is weakened by lack of cost analysis and absence of clinical algorithms.

How the evidence was graded. Electronic databases were searched through June 2006. Experts considered reviews and meta-analyses and weighted the evidence according to a rating scheme. They graded each recommendation on the quality of the literature (levels I, II, or II) and by expert interpretation (strong, moderate, or weak). A strong recommendation required that more than 50% of the experts grade it as strong and the majority of the remainder grade it as moderate.

Most patients with CAP should receive a strongly rated intervention, and the rationale for variation should be apparent from the medical record. With a moderate or weak recommendation, the committee suggested, most physicians would follow the recommended management, but many would not.

When is outpatient treatment appropriate for community-acquired pneumonia (CAP)? Which antibiotics are recommended for outpatient therapy? What are the best prevention strategies? The answers are in the consensus guidelines published earlier this year by the Infectious Diseases Society of America and the American Thoracic Society (IDSA/ATS). The new guidelines update an IDSA guideline published in 2003.

Background. Management (and prevention) of CAP is inconsistent, and there is also emerging resistance of pneumococcus to macrolides.

These guidelines were developed to hasten consistency among caregivers and hospitals in the care of patients with pneumonia. Appropriateness of outpatient care, severity of illness assessment, hospital treatment decisions, ICU care, and choice of antibiotics for high-risk patients and for drug-resistant S pneumonia were reviewed. The joint committee recommended that hospitals standardize care and create policies to increase the vaccination rate.

Cases that test your skills

CASE 1

Your patient is a 45-year-old man with cough, fever, and chills. He has a history of metabolic syndrome, and a 40 pack-year smoking history. He was well until 1 week ago when he went camping in the rain. Over the last 2 days he has had shaking chills, cough productive of green phlegm, and he finds that he gets a bit short-winded when walking stairs. He wonders if he has pneumonia. He is overweight and in no acute distress.

T 101 • P 88 • RR 18 • WT 220 • HT 5 7

Exam Normal other than localized coarse rales in the left posterior lung field; spot O₂ saturation is 96%

What is your diagnosis and initial management?

Which of the following statements are true regarding the outpatient management of pneumonia?

1. If 2 or more CURB-65 criteria are present, the patient should be hospitalized
2. A macrolide is an appropriate choice of treatment for a previously healthy person with no risk of drug resistance
3. A positive chest x-ray or other imaging is required for the diagnosis
4. Blood cultures and sputum cultures must be obtained
5. Antibiotic treatment should be a minimum of 10 days

ANSWERS: A, B, AND C

Diagnosis Community acquired pneumonia—left lobar.

Initial management This patient can be treated as an outpatient based on the severity-of-illness scores in this guideline. He should be treated with antibiotics a minimum of 5 days. With his comorbidities, antibiotic choices include 1) a fluoroquinolone, 2) a beta-lactam plus macrolide, or 3) (in areas with high prevalence of macrolide resistance) a beta-lactam plus doxycycline.

CASE 2

A 76-year-old man is brought into the office by his niece. “I just don’t feel well,” he says. The patient has been increasingly ill over the past week, and his niece is concerned that he seems to have trouble breathing. The patient minimizes his symptoms, but in relaying his history, he is obviously short of breath and cannot talk continuously. He needed a wheelchair to come in from the parking lot (and you know that he is usually spry and ambulatory). He has a history of congestive heart failure, hypertension, type 2 diabetes mellitus, depression, and osteoarthritis. He takes furosemide, potassium, enalapril, lantus insulin, sertraline, and PRN acetaminophen. He has never smoked. He denies PND and orthopnea. He is clearly short of breath and in some mild distress.

T 99 • P 102 • RR 36 • WT 260 • HT 5 9

Exam Remarkable for diffuse rhonchi and wheezing across all lung fields; spot O₂ saturation is 89%

What is your diagnosis and initial management?

The differential diagnosis for this patient includes:

1. Bacterial pneumonia
2. Viral pneumonia
3. Depression
4. Congestive heart failure
5. Pulmonary embolus

ANSWERS: A, B, D, E

Diagnosis This interstitial pattern on the chest x-ray is associated with multiple etiologies, both infectious and non-infectious. Examples include viral pneumonia, opportunistic infections in HIV patients, atypical infections such as mycoplasm, congestive heart failure, and pulmonary embolus.

Initial management Based on severity-of-illness scores, this patient should be admitted to the hospital. He should have further evaluation to identify the etiology.

By definition, CAP is acquired outside a hospital or long-term care facility. However, the new guidelines include ambulatory residents of nursing homes.

Adults with CAP are the focus of the guidelines, not immunocompromised patients, cancer patients receiving chemotherapy, patients on high-dose steroid therapy, or children under 18 years.

Epidemiology. There are about 5.6 million cases of CAP in the United States annually, and the cost is about $8.4 billion.¹ Death rates increase with comorbidities and older age. There are no race or gender differences in morbidity.

Limitations of the guidelines. The decision whether to admit a patient with CAP is crucial, since the majority of the pneumonia care expenditures are the result of in-patient care.² The guidelines do not state the outcomes that were considered or adverse events associated with therapy. It is weakened by lack of cost analysis and absence of clinical algorithms.

How the evidence was graded. Electronic databases were searched through June 2006. Experts considered reviews and meta-analyses and weighted the evidence according to a rating scheme. They graded each recommendation on the quality of the literature (levels I, II, or II) and by expert interpretation (strong, moderate, or weak). A strong recommendation required that more than 50% of the experts grade it as strong and the majority of the remainder grade it as moderate.

Most patients with CAP should receive a strongly rated intervention, and the rationale for variation should be apparent from the medical record. With a moderate or weak recommendation, the committee suggested, most physicians would follow the recommended management, but many would not.

When is outpatient treatment appropriate for community-acquired pneumonia (CAP)? Which antibiotics are recommended for outpatient therapy? What are the best prevention strategies? The answers are in the consensus guidelines published earlier this year by the Infectious Diseases Society of America and the American Thoracic Society (IDSA/ATS). The new guidelines update an IDSA guideline published in 2003.

Background. Management (and prevention) of CAP is inconsistent, and there is also emerging resistance of pneumococcus to macrolides.

These guidelines were developed to hasten consistency among caregivers and hospitals in the care of patients with pneumonia. Appropriateness of outpatient care, severity of illness assessment, hospital treatment decisions, ICU care, and choice of antibiotics for high-risk patients and for drug-resistant S pneumonia were reviewed. The joint committee recommended that hospitals standardize care and create policies to increase the vaccination rate.

Cases that test your skills

CASE 1

Your patient is a 45-year-old man with cough, fever, and chills. He has a history of metabolic syndrome, and a 40 pack-year smoking history. He was well until 1 week ago when he went camping in the rain. Over the last 2 days he has had shaking chills, cough productive of green phlegm, and he finds that he gets a bit short-winded when walking stairs. He wonders if he has pneumonia. He is overweight and in no acute distress.

T 101 • P 88 • RR 18 • WT 220 • HT 5 7

Exam Normal other than localized coarse rales in the left posterior lung field; spot O₂ saturation is 96%

What is your diagnosis and initial management?

Which of the following statements are true regarding the outpatient management of pneumonia?

1. If 2 or more CURB-65 criteria are present, the patient should be hospitalized
2. A macrolide is an appropriate choice of treatment for a previously healthy person with no risk of drug resistance
3. A positive chest x-ray or other imaging is required for the diagnosis
4. Blood cultures and sputum cultures must be obtained
5. Antibiotic treatment should be a minimum of 10 days

ANSWERS: A, B, AND C

Diagnosis Community acquired pneumonia—left lobar.

Initial management This patient can be treated as an outpatient based on the severity-of-illness scores in this guideline. He should be treated with antibiotics a minimum of 5 days. With his comorbidities, antibiotic choices include 1) a fluoroquinolone, 2) a beta-lactam plus macrolide, or 3) (in areas with high prevalence of macrolide resistance) a beta-lactam plus doxycycline.

CASE 2

A 76-year-old man is brought into the office by his niece. “I just don’t feel well,” he says. The patient has been increasingly ill over the past week, and his niece is concerned that he seems to have trouble breathing. The patient minimizes his symptoms, but in relaying his history, he is obviously short of breath and cannot talk continuously. He needed a wheelchair to come in from the parking lot (and you know that he is usually spry and ambulatory). He has a history of congestive heart failure, hypertension, type 2 diabetes mellitus, depression, and osteoarthritis. He takes furosemide, potassium, enalapril, lantus insulin, sertraline, and PRN acetaminophen. He has never smoked. He denies PND and orthopnea. He is clearly short of breath and in some mild distress.

T 99 • P 102 • RR 36 • WT 260 • HT 5 9

Exam Remarkable for diffuse rhonchi and wheezing across all lung fields; spot O₂ saturation is 89%

What is your diagnosis and initial management?

The differential diagnosis for this patient includes:

1. Bacterial pneumonia
2. Viral pneumonia
3. Depression
4. Congestive heart failure
5. Pulmonary embolus

ANSWERS: A, B, D, E

Diagnosis This interstitial pattern on the chest x-ray is associated with multiple etiologies, both infectious and non-infectious. Examples include viral pneumonia, opportunistic infections in HIV patients, atypical infections such as mycoplasm, congestive heart failure, and pulmonary embolus.

Initial management Based on severity-of-illness scores, this patient should be admitted to the hospital. He should have further evaluation to identify the etiology.

By definition, CAP is acquired outside a hospital or long-term care facility. However, the new guidelines include ambulatory residents of nursing homes.

Adults with CAP are the focus of the guidelines, not immunocompromised patients, cancer patients receiving chemotherapy, patients on high-dose steroid therapy, or children under 18 years.

Epidemiology. There are about 5.6 million cases of CAP in the United States annually, and the cost is about $8.4 billion.¹ Death rates increase with comorbidities and older age. There are no race or gender differences in morbidity.

Limitations of the guidelines. The decision whether to admit a patient with CAP is crucial, since the majority of the pneumonia care expenditures are the result of in-patient care.² The guidelines do not state the outcomes that were considered or adverse events associated with therapy. It is weakened by lack of cost analysis and absence of clinical algorithms.

How the evidence was graded. Electronic databases were searched through June 2006. Experts considered reviews and meta-analyses and weighted the evidence according to a rating scheme. They graded each recommendation on the quality of the literature (levels I, II, or II) and by expert interpretation (strong, moderate, or weak). A strong recommendation required that more than 50% of the experts grade it as strong and the majority of the remainder grade it as moderate.

Most patients with CAP should receive a strongly rated intervention, and the rationale for variation should be apparent from the medical record. With a moderate or weak recommendation, the committee suggested, most physicians would follow the recommended management, but many would not.

• What treatment strategy is most effective at reducing mortality?
• What patient characteristics are associated with increased mortality?
• What are the indications for stent placement?

The answers to these questions are summarized below and in the Comparative Effectiveness Review: Comparative Effectiveness of Management Strategies for Renal Artery Stenosis, funded and published by Agency for Healthcare Research and Quality (AHRQ). The review summarizes the current evidence concerning the effectiveness and safety of angioplasty with stent placement compared with medical therapy in the treatment of atherosclerotic renal artery stenosis.

The review team accepted the patient population of original authors, without clearly defining the level of renal artery stenosis. “The population of interest for this report is adults with atherosclerotic renal artery stenosis that is of sufficient severity to warrant aggressive management, either due to resistant hypertension, evidence of kidney damage, or the high likelihood of poor outcomes.” The team considered the following outcomes: blood pressure control, preservation of kidney function, incidence of flash pulmonary edema, and survival rates. Adverse events associated with therapies were also considered.

Review is commissioned to tackle controversy

The Comparative Effectiveness Review notes that 12% to 14% of new dialysis patients in the United States have atherosclerotic renal artery stenosis. It also points out that the utilization of renal artery angioplasty has increased considerably over the last few years, from 7660 cases in 1996 to 18,520 in 2000. The review was commissioned because of the controversy regarding optimal strategies for the evaluation and management of patients with atherosclerotic renal artery stenosis. The Comparative Effectiveness Review is strengthened by excellent summary tables, a review of treatment-associated harm, and an extensive discussion of methods.

In addition to this review of the literature, the government is sponsoring a more definitive trial to determine which patients with atherosclerotic renal artery stenosis would most benefit from angioplasty with stent placement, as opposed to continued aggressive medical treatment. The results of the Cardiovascular Outcomes in Renal Atherosclerotic Lesion (CORAL) Trial, a large, multicenter trial sponsored by the National Institutes of Health, will not be available until 2010.

A review of nearly 40 years of research

The Tufts–New England Medical Center Evidence-Based Practice Center was commissioned by AHRQ to conduct the review. A comprehensive search of the literature included Medline from 1966 to September 6, 2005. A technical expert panel held teleconferences to refine key questions and define parameters for review of the evidence. Researchers gave priority to meta-analyses and systemic reviews. Abstracts of research presented at conferences and symposiums were not considered adequate to be considered. There were 76 references.

Quality assessment of the literature was designated by a 3-category grading system (A—good, B—fair/moderate, and C—poor). For our purposes, the evidence rating is updated to comply with the SORT taxonomy.¹

A search of the literature did not identify any other guidelines for comparison.

Source for this guideline

Balk E, Raman G, Chung M, et al. Comparative Effectiveness Review: Comparative Effectiveness of Management Strategies for Renal Artery Stenosis. (Prepared by Tufts-New England Medical Center Evidence-based Practice Center under Contract No. 290-02-0022). Rockville, Md: Agency for Healthcare Research and Quality; October 2006. Available at: effectivehealthcare.ahrq.gov/repFiles/RAS_Final.pdf. Accessed on April 11, 2007.

Correspondence
Keith B. Holten, MD, 825 Locust Street, Wilmington, Ohio 45177; [email protected].

• What treatment strategy is most effective at reducing mortality?
• What patient characteristics are associated with increased mortality?
• What are the indications for stent placement?

The answers to these questions are summarized below and in the Comparative Effectiveness Review: Comparative Effectiveness of Management Strategies for Renal Artery Stenosis, funded and published by Agency for Healthcare Research and Quality (AHRQ). The review summarizes the current evidence concerning the effectiveness and safety of angioplasty with stent placement compared with medical therapy in the treatment of atherosclerotic renal artery stenosis.

The review team accepted the patient population of original authors, without clearly defining the level of renal artery stenosis. “The population of interest for this report is adults with atherosclerotic renal artery stenosis that is of sufficient severity to warrant aggressive management, either due to resistant hypertension, evidence of kidney damage, or the high likelihood of poor outcomes.” The team considered the following outcomes: blood pressure control, preservation of kidney function, incidence of flash pulmonary edema, and survival rates. Adverse events associated with therapies were also considered.

Review is commissioned to tackle controversy

The Comparative Effectiveness Review notes that 12% to 14% of new dialysis patients in the United States have atherosclerotic renal artery stenosis. It also points out that the utilization of renal artery angioplasty has increased considerably over the last few years, from 7660 cases in 1996 to 18,520 in 2000. The review was commissioned because of the controversy regarding optimal strategies for the evaluation and management of patients with atherosclerotic renal artery stenosis. The Comparative Effectiveness Review is strengthened by excellent summary tables, a review of treatment-associated harm, and an extensive discussion of methods.

In addition to this review of the literature, the government is sponsoring a more definitive trial to determine which patients with atherosclerotic renal artery stenosis would most benefit from angioplasty with stent placement, as opposed to continued aggressive medical treatment. The results of the Cardiovascular Outcomes in Renal Atherosclerotic Lesion (CORAL) Trial, a large, multicenter trial sponsored by the National Institutes of Health, will not be available until 2010.

A review of nearly 40 years of research

The Tufts–New England Medical Center Evidence-Based Practice Center was commissioned by AHRQ to conduct the review. A comprehensive search of the literature included Medline from 1966 to September 6, 2005. A technical expert panel held teleconferences to refine key questions and define parameters for review of the evidence. Researchers gave priority to meta-analyses and systemic reviews. Abstracts of research presented at conferences and symposiums were not considered adequate to be considered. There were 76 references.

Quality assessment of the literature was designated by a 3-category grading system (A—good, B—fair/moderate, and C—poor). For our purposes, the evidence rating is updated to comply with the SORT taxonomy.¹

A search of the literature did not identify any other guidelines for comparison.

Source for this guideline

Balk E, Raman G, Chung M, et al. Comparative Effectiveness Review: Comparative Effectiveness of Management Strategies for Renal Artery Stenosis. (Prepared by Tufts-New England Medical Center Evidence-based Practice Center under Contract No. 290-02-0022). Rockville, Md: Agency for Healthcare Research and Quality; October 2006. Available at: effectivehealthcare.ahrq.gov/repFiles/RAS_Final.pdf. Accessed on April 11, 2007.

Correspondence
Keith B. Holten, MD, 825 Locust Street, Wilmington, Ohio 45177; [email protected].

• What treatment strategy is most effective at reducing mortality?
• What patient characteristics are associated with increased mortality?
• What are the indications for stent placement?

The answers to these questions are summarized below and in the Comparative Effectiveness Review: Comparative Effectiveness of Management Strategies for Renal Artery Stenosis, funded and published by Agency for Healthcare Research and Quality (AHRQ). The review summarizes the current evidence concerning the effectiveness and safety of angioplasty with stent placement compared with medical therapy in the treatment of atherosclerotic renal artery stenosis.

The review team accepted the patient population of original authors, without clearly defining the level of renal artery stenosis. “The population of interest for this report is adults with atherosclerotic renal artery stenosis that is of sufficient severity to warrant aggressive management, either due to resistant hypertension, evidence of kidney damage, or the high likelihood of poor outcomes.” The team considered the following outcomes: blood pressure control, preservation of kidney function, incidence of flash pulmonary edema, and survival rates. Adverse events associated with therapies were also considered.

Review is commissioned to tackle controversy

The Comparative Effectiveness Review notes that 12% to 14% of new dialysis patients in the United States have atherosclerotic renal artery stenosis. It also points out that the utilization of renal artery angioplasty has increased considerably over the last few years, from 7660 cases in 1996 to 18,520 in 2000. The review was commissioned because of the controversy regarding optimal strategies for the evaluation and management of patients with atherosclerotic renal artery stenosis. The Comparative Effectiveness Review is strengthened by excellent summary tables, a review of treatment-associated harm, and an extensive discussion of methods.

In addition to this review of the literature, the government is sponsoring a more definitive trial to determine which patients with atherosclerotic renal artery stenosis would most benefit from angioplasty with stent placement, as opposed to continued aggressive medical treatment. The results of the Cardiovascular Outcomes in Renal Atherosclerotic Lesion (CORAL) Trial, a large, multicenter trial sponsored by the National Institutes of Health, will not be available until 2010.

A review of nearly 40 years of research

The Tufts–New England Medical Center Evidence-Based Practice Center was commissioned by AHRQ to conduct the review. A comprehensive search of the literature included Medline from 1966 to September 6, 2005. A technical expert panel held teleconferences to refine key questions and define parameters for review of the evidence. Researchers gave priority to meta-analyses and systemic reviews. Abstracts of research presented at conferences and symposiums were not considered adequate to be considered. There were 76 references.

Quality assessment of the literature was designated by a 3-category grading system (A—good, B—fair/moderate, and C—poor). For our purposes, the evidence rating is updated to comply with the SORT taxonomy.¹

A search of the literature did not identify any other guidelines for comparison.

Source for this guideline

Balk E, Raman G, Chung M, et al. Comparative Effectiveness Review: Comparative Effectiveness of Management Strategies for Renal Artery Stenosis. (Prepared by Tufts-New England Medical Center Evidence-based Practice Center under Contract No. 290-02-0022). Rockville, Md: Agency for Healthcare Research and Quality; October 2006. Available at: effectivehealthcare.ahrq.gov/repFiles/RAS_Final.pdf. Accessed on April 11, 2007.

Correspondence
Keith B. Holten, MD, 825 Locust Street, Wilmington, Ohio 45177; [email protected].

In January 2003 the American College of Chest Physicians Expert Panel on Lung Cancer Guidelines released its guideline on evaluating a solitary pulmonary nodule (SPN), an intraparenchymal lung lesion <3 cm in diameter unassociated with atelectasis or adenopathy. The objectives of this guideline were to define appropriate evidence-based practices for imaging and diagnostic tests, as well as indications for obtaining a tissue evaluation for the patient with a SPN. This expert panel included physicians from nuclear medicine, oncology, pulmonary medicine, radiology, and thoracic surgery. The major recommendations were summarized in the National Guideline Clearinghouse (available at www.guideline.gov).

The evidence categories for this guideline are diagnosis and management. Outcomes considered were sensitivity and specificity of diagnostic tests and diagnostic yield. No cost analysis was performed.

The committee used a complex recommendation rating scheme (A, B, C, D, I) after comparing levels of evidence (good, fair, or poor) compared with net benefits (substantial, moderate, small/weak, or none). The scheme was then revised to correspond to the grades of recommendation of the Oxford Centre for Evidence-Based Medicine.

Guideline relevance and limitations

Solitary pulmonary nodules are discovered in 150,000 patients per year, and a delay in performing diagnostic studies can have dire consequences for those whose nodule proves malignant.

The guideline is weakened by the lack of a cost-effectiveness analysis.

A lengthy bibliography accompanies the guideline, but the support document does not provide evidence tables.

Guideline development and evidence review

Computerized bibliographic databases including Medline, Cancerlit, CINAHL, HealthStar, the Cochrane Collaboration Database of Abstracts of Reviews of Effectiveness, the National Guideline Clearinghouse, and the National Cancer Institute Physician Data Query database were searched for existing evidence. Priority was given to secondary sources including guidelines, systematic reviews, and meta-analyses. Search terms were lung neoplasms or bronchial neoplasms. Reference lists of review articles were also studied for additional evidence. There were 55 references.

Source for this guideline

Tan BB, Flaherty KR, Kazerooni EA, Iannettoni MD. The solitary pulmonary nodule. Chest 2003; 123(1 suppl):89S–96S.

Other guidelines on solitary pulmonary nodules

ACR Appropriateness Criteria™ for work-up of the solitary pulmonary nodule (SPN). 1995 (revised 2000). This guideline is one in a series of guidelines developed by the American College of Radiology. It ranks the utility of various diagnostic testing modalities based on evidence. This guideline is complex, because there are several “variants” based on the size of the lesion (≥1 cm or ≤1 cm) and the clinical suspicion of cancer (low, moderate to high). The clinical utility for primary care physicians is limited.

Source: Henschke CI, Yankelevitz D, Westcott J, et al. Work-up of the solitary pulmonary nodule. American College of Radiology. ACR Appropriateness Criteria. Radiology 2000; 215(Suppl):607–609. (19 references)

Correspondence
Keith B. Holten, MD, Clinton Memorial Hospital/University of Cincinnati Family Practice Residency, 825 W. Locust St., Wilmington, OH, 45177. E-mail: [email protected].

In January 2003 the American College of Chest Physicians Expert Panel on Lung Cancer Guidelines released its guideline on evaluating a solitary pulmonary nodule (SPN), an intraparenchymal lung lesion <3 cm in diameter unassociated with atelectasis or adenopathy. The objectives of this guideline were to define appropriate evidence-based practices for imaging and diagnostic tests, as well as indications for obtaining a tissue evaluation for the patient with a SPN. This expert panel included physicians from nuclear medicine, oncology, pulmonary medicine, radiology, and thoracic surgery. The major recommendations were summarized in the National Guideline Clearinghouse (available at www.guideline.gov).

The evidence categories for this guideline are diagnosis and management. Outcomes considered were sensitivity and specificity of diagnostic tests and diagnostic yield. No cost analysis was performed.

The committee used a complex recommendation rating scheme (A, B, C, D, I) after comparing levels of evidence (good, fair, or poor) compared with net benefits (substantial, moderate, small/weak, or none). The scheme was then revised to correspond to the grades of recommendation of the Oxford Centre for Evidence-Based Medicine.

Guideline relevance and limitations

Solitary pulmonary nodules are discovered in 150,000 patients per year, and a delay in performing diagnostic studies can have dire consequences for those whose nodule proves malignant.

The guideline is weakened by the lack of a cost-effectiveness analysis.

A lengthy bibliography accompanies the guideline, but the support document does not provide evidence tables.

Guideline development and evidence review

Computerized bibliographic databases including Medline, Cancerlit, CINAHL, HealthStar, the Cochrane Collaboration Database of Abstracts of Reviews of Effectiveness, the National Guideline Clearinghouse, and the National Cancer Institute Physician Data Query database were searched for existing evidence. Priority was given to secondary sources including guidelines, systematic reviews, and meta-analyses. Search terms were lung neoplasms or bronchial neoplasms. Reference lists of review articles were also studied for additional evidence. There were 55 references.

Source for this guideline

Tan BB, Flaherty KR, Kazerooni EA, Iannettoni MD. The solitary pulmonary nodule. Chest 2003; 123(1 suppl):89S–96S.

Other guidelines on solitary pulmonary nodules

ACR Appropriateness Criteria™ for work-up of the solitary pulmonary nodule (SPN). 1995 (revised 2000). This guideline is one in a series of guidelines developed by the American College of Radiology. It ranks the utility of various diagnostic testing modalities based on evidence. This guideline is complex, because there are several “variants” based on the size of the lesion (≥1 cm or ≤1 cm) and the clinical suspicion of cancer (low, moderate to high). The clinical utility for primary care physicians is limited.

Source: Henschke CI, Yankelevitz D, Westcott J, et al. Work-up of the solitary pulmonary nodule. American College of Radiology. ACR Appropriateness Criteria. Radiology 2000; 215(Suppl):607–609. (19 references)

Correspondence
Keith B. Holten, MD, Clinton Memorial Hospital/University of Cincinnati Family Practice Residency, 825 W. Locust St., Wilmington, OH, 45177. E-mail: [email protected].

In January 2003 the American College of Chest Physicians Expert Panel on Lung Cancer Guidelines released its guideline on evaluating a solitary pulmonary nodule (SPN), an intraparenchymal lung lesion <3 cm in diameter unassociated with atelectasis or adenopathy. The objectives of this guideline were to define appropriate evidence-based practices for imaging and diagnostic tests, as well as indications for obtaining a tissue evaluation for the patient with a SPN. This expert panel included physicians from nuclear medicine, oncology, pulmonary medicine, radiology, and thoracic surgery. The major recommendations were summarized in the National Guideline Clearinghouse (available at www.guideline.gov).

The evidence categories for this guideline are diagnosis and management. Outcomes considered were sensitivity and specificity of diagnostic tests and diagnostic yield. No cost analysis was performed.

The committee used a complex recommendation rating scheme (A, B, C, D, I) after comparing levels of evidence (good, fair, or poor) compared with net benefits (substantial, moderate, small/weak, or none). The scheme was then revised to correspond to the grades of recommendation of the Oxford Centre for Evidence-Based Medicine.

Guideline relevance and limitations

Solitary pulmonary nodules are discovered in 150,000 patients per year, and a delay in performing diagnostic studies can have dire consequences for those whose nodule proves malignant.

The guideline is weakened by the lack of a cost-effectiveness analysis.

A lengthy bibliography accompanies the guideline, but the support document does not provide evidence tables.

Guideline development and evidence review

Computerized bibliographic databases including Medline, Cancerlit, CINAHL, HealthStar, the Cochrane Collaboration Database of Abstracts of Reviews of Effectiveness, the National Guideline Clearinghouse, and the National Cancer Institute Physician Data Query database were searched for existing evidence. Priority was given to secondary sources including guidelines, systematic reviews, and meta-analyses. Search terms were lung neoplasms or bronchial neoplasms. Reference lists of review articles were also studied for additional evidence. There were 55 references.

Source for this guideline

Tan BB, Flaherty KR, Kazerooni EA, Iannettoni MD. The solitary pulmonary nodule. Chest 2003; 123(1 suppl):89S–96S.

Other guidelines on solitary pulmonary nodules

ACR Appropriateness Criteria™ for work-up of the solitary pulmonary nodule (SPN). 1995 (revised 2000). This guideline is one in a series of guidelines developed by the American College of Radiology. It ranks the utility of various diagnostic testing modalities based on evidence. This guideline is complex, because there are several “variants” based on the size of the lesion (≥1 cm or ≤1 cm) and the clinical suspicion of cancer (low, moderate to high). The clinical utility for primary care physicians is limited.

Source: Henschke CI, Yankelevitz D, Westcott J, et al. Work-up of the solitary pulmonary nodule. American College of Radiology. ACR Appropriateness Criteria. Radiology 2000; 215(Suppl):607–609. (19 references)

Correspondence
Keith B. Holten, MD, Clinton Memorial Hospital/University of Cincinnati Family Practice Residency, 825 W. Locust St., Wilmington, OH, 45177. E-mail: [email protected].

Answers to these and other questions can be found in a guideline revised within the year by the Evidence-Based Practice Committee of the American Academy of Orthopedic Surgeons. The guideline—revised from a version developed and released in 1996—is divided into 2 phases: care provided by the first-contact primary care physician (the focus of this review), and recommendations for specialists (not addressed in this review).

The major recommendations summarized in the National Guideline Clearinghouse (www.ngc.gov) did not include the excellent care algorithm. For this update, therefore, the source document was accessed. It summarizes the following recommendations for referral to a musculoskeletal specialist (orthopedist, physiatrist, or rheumatologist)—poor response to 12 weeks of treatment, suspected infection, or hemarthrosis.

The evidence categories for this guideline are diagnosis, evaluation, management, and treatment. Targeted patients were adults with longstanding knee pain. Outcomes measured were symptomatic pain relief, improved range of motion, better physical functioning, and complications associated with treatment.

The committee used a recommendation rating scheme of A to D, based on a review of the evidence. Ratings were altered to correspond to the grades of recommendation of the Oxford Centre for Evidence-Based Medicine. (As explained on pages 111 to 120 of this issue, The journal of family practice and many other family-medicine publications will be using an evidence-rating system ranging from A to C. For this review, however, the scheme of A to D originally used by the guideline’s authors has been left intact.)

Limitations of guideline usefulness

Although this guideline was just published, the evidence is complete only through 2000. The bibliography is lengthy, but the support document does not provide evidence tables. The established outcomes set forth were not used to design the algorithm, which also lacks grades of evidence. The guideline is further weakened by the lack of cost-effectiveness analysis.

Guideline development and evidence review

The 1996 guideline was developed by a multidisciplinary group of American Academy of Orthopedic Surgeons, the American Association of Neurological Surgeons, the American College of Physical Medicine and Rehabilitation, and the American College of Rheumatology. The 2003 revision group performed a new literature search for 1990–2000 for human subjects aged 19 years and older. In all, 128 articles were reviewed, 114 references were cited, the evidence was graded, and the original guideline was revised based on the evidence.

Sources for this guideline

American Academy of Orthopaedic Surgeons. AAOS clinical practice guideline on osteoarthritis of the knee. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 2003.

Source document available at: www.aaos.org/wordhtml/pdfs_r/guidelin/suprt_04.pdf. Algorithm available at: www.aaos.org/word-html/pdfs_r/guidelin/chart_oakn.pdf. Accessed on December 30, 2003.

FIGURE
Osteoarthritis of the knee

• Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update.American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum 2000; 43:1905–1915. Available at: www.rheumatology.org/publications/guide-lines/oa-knee/oa-knee.asp. Accessed on December 30, 2003.
• Knee pain or swelling: acute or chronic. University of Michigan Health System. Ann Arbor, Mich: University of Michigan Health System; 2002 Aug. Available at: cme.med.umich. edu/pdf/guideline/knee.pdf.
• Diagnosis and treatment of adult degenerative joint disease (DJD) of the knee. Institute for Clinical Systems Improvement (ICSI). Bloomington, Minn: Institute for Clinical Systems Improvement (ICSI); 2002 May. Available at: www.icsi.org/knowledge/browse_ category.asp?catID=29.
• Pain in osteoarthritis, rheumatoid arthritis, and juvenile chronic arthritis. Simon LS, Lipman AG, Jacox AK, et al. 2nd ed. Glenview, Ill: American Pain Society (APS); 2002. Not available on-line.
• Physical activity in the prevention, treatment, and rehabilitation of diseases. Finnish Medical Society Duodecim. Helsinki, Finland: Duodecim Medical Publications Ltd.; 2002 May 7. Available at: www.ebm-guidelines.com/home.html (fee for access).

Correspondence
Keith B. Holten, MD, Clinton Memorial Hospital/University of Cincinnati Family Practice Residency, 825 W. Locust St., Wilmington, OH, 45177. E-mail: [email protected].

Answers to these and other questions can be found in a guideline revised within the year by the Evidence-Based Practice Committee of the American Academy of Orthopedic Surgeons. The guideline—revised from a version developed and released in 1996—is divided into 2 phases: care provided by the first-contact primary care physician (the focus of this review), and recommendations for specialists (not addressed in this review).

The major recommendations summarized in the National Guideline Clearinghouse (www.ngc.gov) did not include the excellent care algorithm. For this update, therefore, the source document was accessed. It summarizes the following recommendations for referral to a musculoskeletal specialist (orthopedist, physiatrist, or rheumatologist)—poor response to 12 weeks of treatment, suspected infection, or hemarthrosis.

The evidence categories for this guideline are diagnosis, evaluation, management, and treatment. Targeted patients were adults with longstanding knee pain. Outcomes measured were symptomatic pain relief, improved range of motion, better physical functioning, and complications associated with treatment.

The committee used a recommendation rating scheme of A to D, based on a review of the evidence. Ratings were altered to correspond to the grades of recommendation of the Oxford Centre for Evidence-Based Medicine. (As explained on pages 111 to 120 of this issue, The journal of family practice and many other family-medicine publications will be using an evidence-rating system ranging from A to C. For this review, however, the scheme of A to D originally used by the guideline’s authors has been left intact.)

Limitations of guideline usefulness

Although this guideline was just published, the evidence is complete only through 2000. The bibliography is lengthy, but the support document does not provide evidence tables. The established outcomes set forth were not used to design the algorithm, which also lacks grades of evidence. The guideline is further weakened by the lack of cost-effectiveness analysis.

Guideline development and evidence review

The 1996 guideline was developed by a multidisciplinary group of American Academy of Orthopedic Surgeons, the American Association of Neurological Surgeons, the American College of Physical Medicine and Rehabilitation, and the American College of Rheumatology. The 2003 revision group performed a new literature search for 1990–2000 for human subjects aged 19 years and older. In all, 128 articles were reviewed, 114 references were cited, the evidence was graded, and the original guideline was revised based on the evidence.

Sources for this guideline

American Academy of Orthopaedic Surgeons. AAOS clinical practice guideline on osteoarthritis of the knee. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 2003.

Source document available at: www.aaos.org/wordhtml/pdfs_r/guidelin/suprt_04.pdf. Algorithm available at: www.aaos.org/word-html/pdfs_r/guidelin/chart_oakn.pdf. Accessed on December 30, 2003.

FIGURE
Osteoarthritis of the knee

• Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update.American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum 2000; 43:1905–1915. Available at: www.rheumatology.org/publications/guide-lines/oa-knee/oa-knee.asp. Accessed on December 30, 2003.
• Knee pain or swelling: acute or chronic. University of Michigan Health System. Ann Arbor, Mich: University of Michigan Health System; 2002 Aug. Available at: cme.med.umich. edu/pdf/guideline/knee.pdf.
• Diagnosis and treatment of adult degenerative joint disease (DJD) of the knee. Institute for Clinical Systems Improvement (ICSI). Bloomington, Minn: Institute for Clinical Systems Improvement (ICSI); 2002 May. Available at: www.icsi.org/knowledge/browse_ category.asp?catID=29.
• Pain in osteoarthritis, rheumatoid arthritis, and juvenile chronic arthritis. Simon LS, Lipman AG, Jacox AK, et al. 2nd ed. Glenview, Ill: American Pain Society (APS); 2002. Not available on-line.
• Physical activity in the prevention, treatment, and rehabilitation of diseases. Finnish Medical Society Duodecim. Helsinki, Finland: Duodecim Medical Publications Ltd.; 2002 May 7. Available at: www.ebm-guidelines.com/home.html (fee for access).

Correspondence
Keith B. Holten, MD, Clinton Memorial Hospital/University of Cincinnati Family Practice Residency, 825 W. Locust St., Wilmington, OH, 45177. E-mail: [email protected].

Answers to these and other questions can be found in a guideline revised within the year by the Evidence-Based Practice Committee of the American Academy of Orthopedic Surgeons. The guideline—revised from a version developed and released in 1996—is divided into 2 phases: care provided by the first-contact primary care physician (the focus of this review), and recommendations for specialists (not addressed in this review).

The major recommendations summarized in the National Guideline Clearinghouse (www.ngc.gov) did not include the excellent care algorithm. For this update, therefore, the source document was accessed. It summarizes the following recommendations for referral to a musculoskeletal specialist (orthopedist, physiatrist, or rheumatologist)—poor response to 12 weeks of treatment, suspected infection, or hemarthrosis.

The evidence categories for this guideline are diagnosis, evaluation, management, and treatment. Targeted patients were adults with longstanding knee pain. Outcomes measured were symptomatic pain relief, improved range of motion, better physical functioning, and complications associated with treatment.

The committee used a recommendation rating scheme of A to D, based on a review of the evidence. Ratings were altered to correspond to the grades of recommendation of the Oxford Centre for Evidence-Based Medicine. (As explained on pages 111 to 120 of this issue, The journal of family practice and many other family-medicine publications will be using an evidence-rating system ranging from A to C. For this review, however, the scheme of A to D originally used by the guideline’s authors has been left intact.)

Limitations of guideline usefulness

Although this guideline was just published, the evidence is complete only through 2000. The bibliography is lengthy, but the support document does not provide evidence tables. The established outcomes set forth were not used to design the algorithm, which also lacks grades of evidence. The guideline is further weakened by the lack of cost-effectiveness analysis.

Guideline development and evidence review

The 1996 guideline was developed by a multidisciplinary group of American Academy of Orthopedic Surgeons, the American Association of Neurological Surgeons, the American College of Physical Medicine and Rehabilitation, and the American College of Rheumatology. The 2003 revision group performed a new literature search for 1990–2000 for human subjects aged 19 years and older. In all, 128 articles were reviewed, 114 references were cited, the evidence was graded, and the original guideline was revised based on the evidence.

Sources for this guideline

American Academy of Orthopaedic Surgeons. AAOS clinical practice guideline on osteoarthritis of the knee. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 2003.

Source document available at: www.aaos.org/wordhtml/pdfs_r/guidelin/suprt_04.pdf. Algorithm available at: www.aaos.org/word-html/pdfs_r/guidelin/chart_oakn.pdf. Accessed on December 30, 2003.

FIGURE
Osteoarthritis of the knee

• Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update.American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum 2000; 43:1905–1915. Available at: www.rheumatology.org/publications/guide-lines/oa-knee/oa-knee.asp. Accessed on December 30, 2003.
• Knee pain or swelling: acute or chronic. University of Michigan Health System. Ann Arbor, Mich: University of Michigan Health System; 2002 Aug. Available at: cme.med.umich. edu/pdf/guideline/knee.pdf.
• Diagnosis and treatment of adult degenerative joint disease (DJD) of the knee. Institute for Clinical Systems Improvement (ICSI). Bloomington, Minn: Institute for Clinical Systems Improvement (ICSI); 2002 May. Available at: www.icsi.org/knowledge/browse_ category.asp?catID=29.
• Pain in osteoarthritis, rheumatoid arthritis, and juvenile chronic arthritis. Simon LS, Lipman AG, Jacox AK, et al. 2nd ed. Glenview, Ill: American Pain Society (APS); 2002. Not available on-line.
• Physical activity in the prevention, treatment, and rehabilitation of diseases. Finnish Medical Society Duodecim. Helsinki, Finland: Duodecim Medical Publications Ltd.; 2002 May 7. Available at: www.ebm-guidelines.com/home.html (fee for access).

Correspondence
Keith B. Holten, MD, Clinton Memorial Hospital/University of Cincinnati Family Practice Residency, 825 W. Locust St., Wilmington, OH, 45177. E-mail: [email protected].

Would you order a chest film to evaluate an acute exacerbation of chronic obstructive pulmonary disease (COPD)? Which medication would you first prescribe—a short-acting inhaled beta-2 agonist or an anticholinergic bronchodilator?

These are important questions for family physicians who commonly manage acute exacerbations of COPD.

The guideline summarized here was developed by a joint expert panel of the American College of Physicians–American Society of Internal Medicine and the American College of Chest Physicians. Three outcomes were considered: treatment efficacy, 6-month mortality, and relapse, as defined by return visit to the emergency department within 14 days of initial presentation. Systematic reviews with evidence tables were used to analyze data. The rationale for each recommendation is clear and well documented.

We added strength-of-recommendation ratings, which are not in the original guideline.

Limitations of the Guideline and Additional Evidence

Several weaknesses underlie this guideline. The authors found that, despite the importance of COPD, it has been the subject of very few high-quality studies. The highest-quality studies were few in number and had enrolled a small number of participants. The authors did not grade the strength of each recommendation in the summary document or in the detailed manuscripts, making it difficult to rapidly review.

Different diagnostic criteria are used in the source studies, making the context of treatment recommendations difficult to fully understand. Outcome endpoints also varied among studies. Goals for oxygen therapy were not addressed. Antibiotic treatment was based on studies before the emergence of multidrug-resistant organisms, particularly Streptococcus pneumoniae. It did not address tobacco use or smoking cessation, vaccine administration, outpatient management, management of stable COPD, or stratification of patients by severity.

Guideline Development and Evidence Review

Literature searches were performed using MEDLINE (1966–2000), EMBASE (1966– 2000), Health Star (1966–2000), and the Cochrane Controlled Trials Register (2000, Issue 1).

Search strategies included the index terms and text words chronic obstructive pulmonary disease and acute exacerbation and specific terms relating to interventions and outcomes. Variations on several search strategies were tested to locate the greatest number of relevant articles. Reference lists of retrieved articles were also examined. In all, 770 source articles were found.

Two other Guidelines for COPD

• Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Bethesda, Md: Global Initiative for Chronic Obstructive Lung Disease, World Health Organization/National Heart, Lung, and Blood Institute; 2001. Various pagings. (Web access at: www.goldcopd.com.)
• Veterans Health Administration (VHA). Clinical practice guideline for the management of chronic obstructive pulmonary disease. Version 1.1a. Washington, DC: Department of Veterans Affairs (US), Veterans Health Administration; 1999 Aug. 116 p. (Web access at: www.oqp.med.va.gov/cpg/COPD/ COPD_base.htm).

FIGURE
Emphysematous dysfunction in COPD

Correspondence
Keith B. Holten, MD, Clinton Memorial Hospital/University of Cincinnati Family Practice Residency, 825 W. Locust St., Wilmington, OH, 45177. E-mail: [email protected].

Would you order a chest film to evaluate an acute exacerbation of chronic obstructive pulmonary disease (COPD)? Which medication would you first prescribe—a short-acting inhaled beta-2 agonist or an anticholinergic bronchodilator?

These are important questions for family physicians who commonly manage acute exacerbations of COPD.

The guideline summarized here was developed by a joint expert panel of the American College of Physicians–American Society of Internal Medicine and the American College of Chest Physicians. Three outcomes were considered: treatment efficacy, 6-month mortality, and relapse, as defined by return visit to the emergency department within 14 days of initial presentation. Systematic reviews with evidence tables were used to analyze data. The rationale for each recommendation is clear and well documented.

We added strength-of-recommendation ratings, which are not in the original guideline.

Limitations of the Guideline and Additional Evidence

Several weaknesses underlie this guideline. The authors found that, despite the importance of COPD, it has been the subject of very few high-quality studies. The highest-quality studies were few in number and had enrolled a small number of participants. The authors did not grade the strength of each recommendation in the summary document or in the detailed manuscripts, making it difficult to rapidly review.

Different diagnostic criteria are used in the source studies, making the context of treatment recommendations difficult to fully understand. Outcome endpoints also varied among studies. Goals for oxygen therapy were not addressed. Antibiotic treatment was based on studies before the emergence of multidrug-resistant organisms, particularly Streptococcus pneumoniae. It did not address tobacco use or smoking cessation, vaccine administration, outpatient management, management of stable COPD, or stratification of patients by severity.

Guideline Development and Evidence Review

Literature searches were performed using MEDLINE (1966–2000), EMBASE (1966– 2000), Health Star (1966–2000), and the Cochrane Controlled Trials Register (2000, Issue 1).

Search strategies included the index terms and text words chronic obstructive pulmonary disease and acute exacerbation and specific terms relating to interventions and outcomes. Variations on several search strategies were tested to locate the greatest number of relevant articles. Reference lists of retrieved articles were also examined. In all, 770 source articles were found.

Two other Guidelines for COPD

• Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Bethesda, Md: Global Initiative for Chronic Obstructive Lung Disease, World Health Organization/National Heart, Lung, and Blood Institute; 2001. Various pagings. (Web access at: www.goldcopd.com.)
• Veterans Health Administration (VHA). Clinical practice guideline for the management of chronic obstructive pulmonary disease. Version 1.1a. Washington, DC: Department of Veterans Affairs (US), Veterans Health Administration; 1999 Aug. 116 p. (Web access at: www.oqp.med.va.gov/cpg/COPD/ COPD_base.htm).

FIGURE
Emphysematous dysfunction in COPD

Correspondence
Keith B. Holten, MD, Clinton Memorial Hospital/University of Cincinnati Family Practice Residency, 825 W. Locust St., Wilmington, OH, 45177. E-mail: [email protected].

Would you order a chest film to evaluate an acute exacerbation of chronic obstructive pulmonary disease (COPD)? Which medication would you first prescribe—a short-acting inhaled beta-2 agonist or an anticholinergic bronchodilator?

These are important questions for family physicians who commonly manage acute exacerbations of COPD.

The guideline summarized here was developed by a joint expert panel of the American College of Physicians–American Society of Internal Medicine and the American College of Chest Physicians. Three outcomes were considered: treatment efficacy, 6-month mortality, and relapse, as defined by return visit to the emergency department within 14 days of initial presentation. Systematic reviews with evidence tables were used to analyze data. The rationale for each recommendation is clear and well documented.

We added strength-of-recommendation ratings, which are not in the original guideline.

Limitations of the Guideline and Additional Evidence

Several weaknesses underlie this guideline. The authors found that, despite the importance of COPD, it has been the subject of very few high-quality studies. The highest-quality studies were few in number and had enrolled a small number of participants. The authors did not grade the strength of each recommendation in the summary document or in the detailed manuscripts, making it difficult to rapidly review.

Different diagnostic criteria are used in the source studies, making the context of treatment recommendations difficult to fully understand. Outcome endpoints also varied among studies. Goals for oxygen therapy were not addressed. Antibiotic treatment was based on studies before the emergence of multidrug-resistant organisms, particularly Streptococcus pneumoniae. It did not address tobacco use or smoking cessation, vaccine administration, outpatient management, management of stable COPD, or stratification of patients by severity.

Guideline Development and Evidence Review

Literature searches were performed using MEDLINE (1966–2000), EMBASE (1966– 2000), Health Star (1966–2000), and the Cochrane Controlled Trials Register (2000, Issue 1).

Search strategies included the index terms and text words chronic obstructive pulmonary disease and acute exacerbation and specific terms relating to interventions and outcomes. Variations on several search strategies were tested to locate the greatest number of relevant articles. Reference lists of retrieved articles were also examined. In all, 770 source articles were found.

Two other Guidelines for COPD

• Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Bethesda, Md: Global Initiative for Chronic Obstructive Lung Disease, World Health Organization/National Heart, Lung, and Blood Institute; 2001. Various pagings. (Web access at: www.goldcopd.com.)
• Veterans Health Administration (VHA). Clinical practice guideline for the management of chronic obstructive pulmonary disease. Version 1.1a. Washington, DC: Department of Veterans Affairs (US), Veterans Health Administration; 1999 Aug. 116 p. (Web access at: www.oqp.med.va.gov/cpg/COPD/ COPD_base.htm).

FIGURE
Emphysematous dysfunction in COPD

Correspondence
Keith B. Holten, MD, Clinton Memorial Hospital/University of Cincinnati Family Practice Residency, 825 W. Locust St., Wilmington, OH, 45177. E-mail: [email protected].