Modified tool designed to ease guideline choices

Case descriptions

Case 1. A second-year resident returns from a cardiology rotation in a tertiary care centre. When evaluating a patient for their cardiovascular disease risk, the resident suggests measuring apolipoprotein B and lipoprotein a levels to help decide whether statins should be initiated. These recommendations differ from the 2023 PEER simplified lipid guideline, where measurement of lipoprotein a and apolipoprotein B evels is not recommended.²

Case 2. You have recently read about the 2023 Osteoporosis Canada guidelines³ and are considering requesting a bone mineral density scan for a 70-year-old male patient whose medical history is unremarkable aside from hypertension, and who has never sustained a fragility fracture in the past. These recommendations differ from the Canadian Task Force on Preventive Health Care 2023 guidelines on screening to prevent fragility fractures.⁴

How can we use these moments and divergences to help foster critical thinking while acknowledging the lack of time in a busy clinical practice?

The proliferation of CPGs has led to an information overload for physicians seeking guidance in their medical decision making. While the AGREE (Appraisal of Guidelines for Research and Evaluation) criteria were designed to assess the quality of CPGs,⁵ they are tedious to use in clinical practice. Shaughnessy and colleagues’ G-TRUST¹ has emerged as a promising alternative. Its comprehensive nature may still make its use unrealistic in an active clinical care context. This article proposes a shortened version of G-TRUST to make it even more usable for busy clinicians (Box 1).¹ To do this we highlighted the 3 key threat elements of the previously published G-TRUST and proposed examples of how we can think about these criteria. We believe it is useful to quickly appraise a CPG and select guidelines of the best quality that align with clinical realities and patient needs in situations involving multiple CPG options.

From the original G-TRUST, we selected key elements to identify potential areas of concern in CPGs: relevance, interpretation, and confidence. Relevance involves assessing the usefulness of guideline recommendations in a specific practice, considering factors such as the similarity of patients, populations, and contexts. Additionally, ask yourself whether the recommendations address patient-oriented outcomes, if they are clear, and if you have all the information to implement them. Feasibility should include the time required to implement recommendations, a concept referred to as time needed to treat.⁶

The interpretation aspect focuses on potential conflicts of interest (financial or intellectual) as these may influence trust in the content of the recommendations.

When an investigator’s relationship [of any kind] affects, or gives the appearance of affecting, his/her objectivity in the conduct of scholarly or scientific research, a conflict of interest is said to occur. The relationship does not have to be a personal nor a financial one, [it can also be intellectual].⁷

The interpretation section also includes taking a look at the diversity of the panel members contributing to the guideline to ensure the inclusion of the different concerned parties (family physicians, patients, etc).

Last, the confidence section pertains to the factual basis underlying the recommendations and the transparency of this information. The systematic reviews should be easily accessible. The use of rigorous methodologies such as GRADE (Grading of Recommendations Assessment, Development and Evaluation) and overall transparency in presenting the evidence supporting the recommendations are important. By evaluating CPGs through these lenses, health care practitioners can identify and address potential threats to the reliability and applicability of clinical guidance in their practices.

How did this adapted tool come about?

Increasing the appropriateness of medical care in primary care settings is a challenge. Reaching clinicians through continuing professional development is often the chosen approach to tackle low-value care. In 2011 some members of the Ontario College of Family Physicians developed a practical workshop to discuss appropriate care. In 2015 the Practising Wisely workshop emerged as a collaborative effort between the Ontario College of Family Physicians, physicians engaged with the Choosing Wisely Canada campaign, and other partners. The program focused on promoting wise clinical decision making and enhancing patient care through evidence-based practices. Over the years it garnered momentum and support, and the program underwent a comprehensive update in 2019, leveraging the expertise of a national scientific committee to ensure the program’s content remained aligned with the latest medical insight and recommendations.

Within the Practising Wisely workshop, a substantial section is dedicated to shared decision making. A central element of this segment is the presentation of the simplified lipid guideline endorsed by the College of Family Physicians of Canada, which was introduced in 2015 and updated in 2023.² However, this guideline differs in some respects from recommendations put forth in other established sources, such as the Canadian Cardiovascular Society guidelines.⁸ These divergences prompt a noteworthy reaction from many learners who partake in the program. For this reason, the program’s organizers recognized the need to provide a clear and concise explanation for their decision to endorse and present one CPG more than the other. The simplified G-TRUST was created in response to this need.

Since then, many facilitators have reused the tool in various clinical scenarios and environments, as well as in formal teaching and continuing professional development conferences. In a workshop at the Preventing Overdiagnosis Conference in 2023, many participants reported finding the tool useful and user friendly (mostly when used repetitively) for selecting CPGs they can trust.⁹

How to use the tool

The adapted tool emphasizes a clear and concise presentation of information, making it accessible for busy practitioners. Its user-friendly format and focus on essential criteria help save time without compromising the quality of decision making. By ensuring that CPGs align with patient-oriented practices, the tool is designed to contribute to more tailored and effective patient care. Furthermore, it encourages critical appraisal of CPG recommendations, fostering evidence-based practice. At any point, if any concerns are identified, the use of a CPG should be reconsidered.

While the tool can be used to critically appraise a CPG, we believe that its strength lies in its capacity to compare key features of 2 CPGs quickly to help physicians and learners select the appropriate guideline for their practices.

Case resolutions

Case 1. You ask your resident to use the simplified G-TRUST tool to compare CPGs (Table 1).^2,8 After comparing the 2 cardiovascular disease prevention guidelines, your resident decides to follow the PEER simplified lipid guideline.

Case 2. For your specific patient question, after using the simplified G-TRUST tool, you choose to use the Canadian Task Force on Preventive Health Care guideline on screening to prevent fragility fractures rather than the Osteoporosis Canada guideline (Table 2).^3,4

In each situation the tool facilitated the adoption of CPGs that better corresponded to patient and practitioner needs (Box 2).¹ Not only was this tool used to make evidence-based clinical decisions, but it also helped shape critical thinking and provided a tool to use when presented with conflicting recommendations.