These focal points eventually become boldface statements in the final manuscript, explained Dr. Rosenfeld. The cerumen document includes 12 such statements, the first being Clinicians should diagnose cerumen impaction when an accumulation of cerumen (1) is associated with symptoms, or (2) prevents needed assessment of the ear, or (3) both. Each focal point or statement is followed by several paragraphs of graded evidence and discussion, added Dr. Rosenfeld.
Explore This IssueNovember 2008
Each section of the guidelines is written by different panel members, said Dr. Smith. There is a primary author and secondary author of each one, he explained, adding that this ensures multidisciplinary input. The entire panel then reviews the document for accuracy and relevance and grades the recommendations as a group, he explained.
Grading assesses the harms and benefits of following a recommendation or statement based on the level of evidence in the literature, explained Dr. Rosenfeld. We assign a certain level of enthusiasm to each recommendation, he said.
For the cerumen publication, the panel devised a new definition of cerumen impaction and explained how to diagnose it, when to remove it, and in which populations physicians should look for impaction, said Dr. Wetmore. Adults may complain about their ears being plugged, but children and cognitively impaired adults who may have trouble hearing due to cerumen impaction may not be able to express themselves, he said. We produced guidelines with these various types of patients in mind.
The Review Process
Once a draft is completed, it undergoes a review process, said Dr. Rosenfeld. Guidelines are assessed with a Yale Center for Medical Informatics tool called Guide-Line Implementability Appraisal (GLIA). It puts them under a microscope, said Dr. Rosenfeld. It takes apart the boldface statements and supporting text and makes sure information is clear, actionable, and can be implemented, he said.
The in-house GLIA review helps determine what barriers exist to implementing each recommendation statement, explained Ms. Haidari. The panel then arrives at a solution to this barrier or changes the recommendations statement, she said.
After this process, the panel sends the manuscript out for external peer review, said Ms. Haidari. They are sent to peer reviewers with expertise in the clinical field and to the external societies that the guidelines may impact, she said. Close to 20 people may review them.
Their feedback is collated into a giant document and given to the panel chair who then integrates comments into a revised version, which is vetted by the full panel to create the final version, said Dr. Rosenfeld.
Final Approval and Publication
Once the review process is complete, the AAO-HNS board of directors assesses the document for final approval, said Ms. Haidari. The organization submits the guidelines for publication in the academy journal and to the National Guideline Clearinghouse for posting on its Web site.