A novel method of guideline development for the diagnosis and management of mild to moderate hypertension

Background. There are large numbers of clinical guidelines available coveri ng many clinical areas. However, the variable quality of their content has meant that doctors may have been offered advice that has been poorly resear ched or is of a conflicting nature. It has been shown that local involvemen t in guideline development increases the likelihood of their use. Aim, To develop a guideline to be used by general practitioners in six prac tices in Birmingham from existing evidence-based guidelines. Method. Recommendations from the four most cited international hypertension guidelines, and the more recently published New Zealand guidelines, were d ivided into subject areas and tabulated to facilitate direct comparison. Wh ere there was complete or majority (greater than or equal to 3/5) agreement , the recommendation was taken as acceptable for inclusion in the new guide line. Where there was disagreement (less than or equal to 2/5), recommendat ions were based on the best available evidence following a further MEDLINE literature search and critical appraisal of the relevant literature. Each r ecommendation was accompanied by a grade of evidence (A-D), as defined by t he Canadian Hypertension Society, and an 'action required' statement of eit her 'must', 'should', or 'could', based on the Eli-Lilly National Clinical Audit Centre Hypertension Audit criteria. The recommendations were summariz ed into a guideline algorithm and a supporting document The final format of both parts of the guideline was decided after consultation with the practi ce teams. The practices individually decided on methods of data collection. Results. The guideline was presented as a double-sided, A4 laminated sheet and an A4 bound supporting document containing a synthesis of the original guidelines in tabular form, a table of the resulting recommendations, and a ppendices of current literature reviews on areas of disagreement. The conte nt of the final Birmingham Clinical Effectiveness Group (BCEG) guideline di ffered minimally from any of the original guidelines. Conclusion, The main strength of this method of guideline development may l ie, not in the actual content of the resulting guideline, but in the streng th of ownership felt by the BCEG and the practices following its developmen t. While the full process is unlikely to be possible for general practition ers working outside an academic environment, the techniques used could prov ide a framework for practitioners to adapt national and international guide lines for use at a local level.