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The evolution of the American College of Chest Physicians consensus on antithrombotic therapy is reviewed, specifically with regard to the prevention and treatment of venous thromboembolism and the rules of evidence applied. A perspective on the impact of the recommendations is offered.
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The recommendations of the Fifth American College of Chest Physicians (ACCP) Consensus Conference on Antithrombotic Therapy are reviewed, with a focus on outpatient anticoagulation management in adults. Numerous therapeutic recommendations have changed since the Fourth ACCP Consensus Conference on Antithrombotic Therapy. The system of grading recommendations has been modified to emphasize clinically important differences and to take into account the benefit-risk ratio of each treatment option. The International Normalized Ratio (INR) goal is now expressed as a specific target value within a range rather than simply an INR range. The recommendations of the fifth conference cover initiation of warfarin therapy, hemorrhagic complications, management of excessive anticoagulation, interruption of warfarin therapy for patients requiring surgery, nonvalvular atrial fibrillation, cardioversion in patients with atrial fibrillation, valvular heart disease, mechanical and biological prosthetic heart valves, coronary artery disease, saphenous vein and internal mammary artery bypass grafts, peripheral arterial occlusive disease, prevention of venous thromboembolism, treatment of venous thromboembolism, stroke prevention in patients with cerebrovascular disease, and pregnancy. Since the fourth consensus conference, new anticoagulation therapies and indications have emerged; the recommendations of the Fifth ACCP Consensus Conference on Antithrombotic Therapy have provided practitioners with a resource of immense value.
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The latest guidelines for the prevention of venous thromboembolism were published by the American College of Chest Physicians in September 2004. This set of updated guidelines represents a discussion of treatments of venous thrombosis, thromboprophylaxis, and revision of those published in 2001. These guidelines propose some "official" recommendations for health-care providers for women during the peripartum period. The purpose of this article is to settle some ambiguity and to present these recommendations in a clinical format.
Atrial fibrillation remains a common and challenging problem following cardiac surgery. The American College of Chest Physicians, through the Health and Science Policy Committee, established a panel to develop a set of clinical practice guidelines for the management or prophylaxis of atrial fibrillation or flutter in patients undergoing coronary artery bypass surgery. The panel based its guidelines on a systematic review of the literature that included a computerized search of PubMed and CENTRAL, the Cochrane Collaboration database, as well as a search of selected journals and references in key articles. Studies were eligible for review if they were controlled trials. Paired reviewers assessed the quality of each eligible study and extracted relevant data. The resulting data were assembled into evidence tables organized by key management questions. The panel derived recommendations that were based on this review of evidence and were formulated according to the ACCP protocol for grading evidence and strength of recommendations.
This article describes the methodology for the Seventh American College of Chest Physicians (ACCP) Conference on Antithrombotic and Thrombolytic Therapy: Evidence-Based Guidelines. Guideline authors began by specifying the population, the intervention and alternative, and the outcomes for each clinical question, and defined the criteria for eligible articles, including methodological criteria, for each recommendation. Librarians, in collaboration with guideline authors and methodologists, conducted systematic searches for evidence. Guideline authors systematically evaluated the evidence, considered the full range of benefits, risks, inconvenience, and costs associated with alternative management strategies, considered patients' underlying values and preferences, and made recommendations accordingly. To increase the likelihood that the recommendations adequately represent patient values and preferences, the development process included a review of recommendations by research methodologists, practicing generalists, and specialists. Chapters are organized so that evidence is clearly linked to the relevant recommendations, and that recommendations particularly sensitive to underlying values and preferences are explicitly identified. Authors paid careful attention to the strength of the underlying evidence and to the balance between risks and benefits, which are both reflected in the grades of recommendations. Thus, improvements to the process of making recommendations for the ACCP guidelines include the explicit definition of questions, transparent eligibility criteria for including studies, and the specification of values and preferences underlying recommendations where they are particularly relevant. In combination with our previous practice of grading recommendations according to their strength, and the methodological quality of the supporting studies, these innovations establish our guidelines as, by and large, evidence based.
AIM: To assess the value of the British Thoracic Society (BTS) and the American College of Chest Physicians (ACCP) guidelines to predict which patients with non-purulent parapneumonic effusions (PPE) warrant chest tube drainage. METHODS: A retrospective chart review was performed on all patients who underwent thoracentesis because of a PPE over a 10-year period at a Spanish medical center. Classification of PPE as complicated (CPPE) or uncomplicated (UPPE) was based on the clinician's decision to insert a chest tube to resolve the effusion. Empyema was defined as pus in the pleural space. Data collected included patient demographics, size of the effusion, and microbiological and pleural fluid chemistries that might influence the physician's decision to place a chest tube. RESULTS: Of the 240 patients with PPE who entered the study, 85 had UPPE, 67 had CPPE, and 88 had empyema. Individual pleural fluid parameters, namely a pH<7.20, a glucose<40 mg/dL or <60 mg/dL, a LDH>1000 U/L or a positive culture had a relatively high specificity (from 78% for LDH to 94% for glucose<40 mg/dL), but low to moderate sensitivity (from 25% for culture to 73% for LDH) in predicting the need for chest tube placement in non-purulent PPE. While pleural fluid cultures performed poorly in discriminating UPPE from CPPE (likelihood ratio positive 1.7), effusion's size performed the best (likelihood ratio positive 5.7). BTS and ACCP guidelines yielded measures of sensitivity (98% and 97%, respectively), and negative likelihood ratio (0.03 and 0.05, respectively) for identifying a CPPE. CONCLUSIONS: Both guidelines have similar accuracy and perform satisfactorily in distinguishing CPPE from UPPE, albeit at an admissible cost of needlessly increasing chest tube drainage.
CONTEXT: Guidelines on the use of prophylaxis in venous thromboembolism (VTE) are poorly implemented in clinical practice. OBJECTIVE: To evaluate the extent to which the American College of Chest Physicians (ACCP) 2001 guidelines on VTE prophylaxis are adhered to in clinical practice by determining whether patients admitted to a medical center with an objective diagnosis of VTE had received adequate prophylaxis. METHODS: The medical records of medical and surgery patients with an objective diagnosis of VTE were reviewed. Patients were classified as having either preventable or nonpreventable VTE according to indication for prophylaxis, VTE risk, and adequacy of prophylaxis if administered. Adequacy was determined by adherence to the ACCP 2001 guidelines. RESULTS: Of 44 patients, 17 (38.6%) had not received adequate prophylaxis and were classified as having potentially preventable VTE. Venous thromboembolism developed in the remaining 27 (61.4%) patients despite adequate prophylaxis. In general, adequate prophylaxis rates were lower among surgery patients compared with medical patients. Four (80%) of the very-high-risk surgery patients received inadequate prophylaxis. The most common VTE risk factor in both categories was immobility. CONCLUSIONS: Adherence to the ACCP guidelines is suboptimal, with a substantial proportion of patients with VTE receiving inadequate prophylaxis. The additional finding that the incidence of VTE is high despite adequate prophylaxis indicates that the guidelines may need to be reevaluated.
OBJECTIVE: Provide explicit expert-based consensus recommendations for the management of adults with primary and secondary spontaneous pneumothoraces in an emergency department and inpatient hospital setting. The use of opinion was made explicit by employing a structured questionnaire, appropriateness scores, and consensus scores with a Delphi technique. The guideline was designed to be relevant to physicians who make management decisions for the care of patients with pneumothorax. OPTIONS: Decisions for observation, chest tube placement, surgical interventions, and radiographic imaging. OUTCOMES: Effectiveness of pneumothorax resolution, duration of and patient tolerance of care, and pneumothorax recurrence. EVIDENCE: Literature review from 1967 to January 1999 and Delphi questionnaire submitted in three iterations to a multidisciplinary physician panel. VALUES: The guideline development group determined by consensus the relevant outcomes to be considered in developing the Delphi questionnaire. BENEFITS, HARMS, AND COSTS: The type and magnitude of benefits, harms, and costs expected for patients from guideline implementation. RECOMMENDATIONS: Management decisions vary between patients with primary or secondary pneumothoraces, with observation of small pneumothoraces being appropriate only for primary pneumothoraces. The level of consensus varies regarding the specific interventions indicated, but agreement exists for the general principles of care. VALIDATION: Recommendations were peer reviewed by physician experts and were reviewed by the American College of Chest Physicians (ACCP) Health and Science Policy Committee. IMPLEMENTATION: The guideline recommendations will be published in printed and electronic form with distribution of synopses for patients and health care providers. Contents of the guideline will be incorporated into continuing medical education programs. SPONSORS: The ACCP.
While grading the strength of recommendations and the quality of underlying evidence enhances the usefulness of clinical guidelines, the profusion of guideline grading systems undermines the value of the grading exercise. An American College of Chest Physicians (ACCP) task force formulated the criteria for a grading system to be utilized in all ACCP guidelines that included simplicity and transparency, explicitness of methodology, and consistency with current methodological approaches to the grading process. The working group examined currently available systems, and ultimately modified an approach formulated by the international GRADE group. The grading scheme classifies recommendations as strong (grade 1) or weak (grade 2), according to the balance among benefits, risks, burdens, and possibly cost, and the degree of confidence in estimates of benefits, risks, and burdens. The system classifies quality of evidence as high (grade A), moderate (grade B), or low (grade C) according to factors that include the study design, the consistency of the results, and the directness of the evidence. For all future ACCP guidelines, The College has adopted a simple, transparent approach to grading recommendations that is consistent with current developments in the field. The trend toward uniformity of approaches to grading will enhance the usefulness of practice guidelines for clinicians.
The number of patients with community-acquired pneumonia (CAP) who are being treated at home is increasing for a variety of reasons. These reasons include the increased availability and cost considerations of oral antibiotics that have been shown to be effective, as well as the consideration of patient and family preferences. However, there is still considerable variability in strategies for the management of patients with CAP. This American College of Chest Physicians position statement, which was cosponsored by the American Academy of Home Care Physicians, provides recommendations on the various aspects of home care for patients with this condition. Included are recommendations for evaluation and diagnosis in the home environment and the determination of the site of care, and an outline of an in-home management plan. The position statement also provides recommendations for issues related to patient and caregiver commitment to the plan, and for monitoring and follow-up. Recommendations are directed toward immunocompetent adult patients with CAP who are at home or in other unskilled residential facilities. These patients can include previously healthy individuals or chronically ill individuals who choose not to go to the hospital, or hospitalized patients who are completing a hospital discharge plan. The recommendations in this statement take into consideration the best course of action for the patient, as determined by incorporating the most recent evidence with clinician judgment and patient preferences. These recommendations also consider the available resources. Therefore, these recommendations may not apply to every patient, and interventions may need to be structured based on the individual. In addition to providing recommendations for the home care management of patients with CAP, we hope that this clinical policy statement will alert readers to the need for more scientific evidence related to the clinical and psychosocial issues associated with managing this condition.
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Acute and chronic pulmonary and cardiac diseases often have a high mortality rate, and can be a source of significant suffering. Palliative care, as described by the Institute of Medicine, "seeks to prevent, relieve, reduce or soothe the symptoms of disease or disorder without effecting a cure... Palliative care in this broad sense is not restricted to those who are dying or those enrolled in hospice programs." The American College of Chest Physicians strongly supports the position that such palliative and end-of-life care of the patient with an acute devastating or chronically progressive pulmonary or cardiac disease and his/her family should be an integral part of cardiopulmonary medicine. This care is best provided through an interdisciplinary effort by competent and experienced professionals under the leadership of a knowledgeable and compassionate physician. To that end, it is hoped that this statement will serve as a framework within which physicians may develop their own approach to the management of patients requiring palliative care.
The primary purpose of a Consensus Conference is to provide informed guidance on treatment decisions, assisting clinicians to make the optimal therapeutic choice for the patient, and providing protection against unjustified malpractice actions. The First American College of Chest Physicians (ACCP) Consensus Conference took place in 1985 and, using a systematic approach, provided recommendations for antithrombotic therapy based on published studies, and graded those recommendations on the level of clinical evidence. The European Consensus Conference was convened in 1991 to build on this process. During this period, the main developments included the introduction and widespread use of new thromboprophylactic agents such as low-molecular-weight heparins, and improved risk assessment, including an awareness that out-patients and general medical patients may also be at risk. Subsequently, the recommendations have been carefully reviewed and updated by experts who represent the extensive range of opinions in the field. The latest International Consensus Statement was published in 1997, and the most recent ACCP Consensus in 1998 and they provide extensive practice guidelines in the management of venous thromboembolism.
The primary purpose of a Consensus Conference is to provide informed guidance on treatment decisions, assisting clinicians to make the optimal therapeutic choice for the patient, and providing protection against unjustified malpractice actions. The First American College of Chest Physicians (ACCP) Consensus Conference took place in 1985 and, using a systematic approach, provided recommendations for anti-thrombotic therapy based on published studies, and graded those recommendations on the level of clinical evidence. The European Consensus Conference was convened in 1991 to build on this process. During this period, the main developments included the introduction and widespread use of new thromboprophylactic agents such as low-molecular-weight heparins, and improved risk assessment, including an awareness that outpatients and general medical patients may also be at risk. Subsequently, the recommendations have been carefully reviewed and updated by experts who represent the extensive range of opinions in the field. The latest International Consensus Statement was published in 1997, and the most recent ACCP Consensus in 2001 and they provide extensive practice guidelines in the management of venous thromboembolism.