"If you think education is expensive,
try ignorance."
Bok's Law1
The present issue of Revista Española de Cardiología is privileged to include 2 European Society of Cardiology (ESC) Guidelines for clinical practice.2,3 It is therefore an appropriate moment to discuss the importance as well as the implications of these type of documents. We shall provide a brief overview of the history and somewhat complex process involved in their development, outline the editorial policy recommended by the ESC and endorsed by the Sociedad Española de Cardiología (SEC, Spanish Society of Cardiology) and finally, describe the approach we feel should be taken toward their publication in Revista Española de Cardiología.
BACKGROUND
Guidelines for Clinical Practice are defined as "systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances."4 Its objectives include synthesizing the scientific evidence available, improving healthcare quality, ensuring consistency in clinical practice, increasing cost-effectiveness, guiding the regulatory agencies and identifying the main areas of uncertainty in which further efforts in research are needed.4-8 The implementation of practice guidelines clearly improves healthcare quality and promotes consistent medical care under similar clinical situations.9-12 In reality, the development and distribution of such guidelines in the last 2 decades is in line with the growing acceptance of evidence-based medicine as a useful tool for optimizing medical practice. Furthermore, cardiology is one of the medical specialties in which the performance of randomized studies has been most widely accepted. Nevertheless, we also know that only a few of the decisions we take in medical practice are based on controlled studies. The possible limitations of the practice guidelines include the fact that it is not always easy or appropriate to standardize the treatment of patients with frequently heterogeneous characteristics (requiring individualized care) in addition to the fact that strict compliance with these guidelines (sometimes for reasons related to medical law) may supplant relevant aspects of clinical experience and the patients' own interests.4-12
Methodological considerations referring to quality standards are less familiar, but should still be taken into consideration when drawing up guidelines.4-8,13-17 In summary, 5 basic steps should be followed:
1. Identify and define the specific topic and process.
2. Choose the group of experts (ideally multidisciplinary panel), and define their tasks.
3. Select and assess the available evidence through systematic reviews, using a specific methodology (e.g., Cochrane's Library, available at: www.cochrane.org).
4. Convert levels of evidence into grades of recommendation. It is important to clarify the value given to the "opinion" of the experts and also to analyze the actual costs and possibilities of application.
5. Perform an outside review (by clinical experts, epidemiologists and potential users) to ensure validity, clarity and applicability.
Not all practice guidelines are based on quality and independence. In fact, despite the evident qualitative improvements introduced over time, there are still important shortcomings in their formulation.18-21 One might even say that frequently the "guidelines are not adhering to the guidelines."20 In a recent study18 only 5% of the practice guidelines for medical specialties fulfilled the 3 basic quality criteria (description of the professionals developing them, the strategy used for search of evidence, and defining the grades of recommendation). Possible conflicts of interest among participants should also be addressed in order to guarantee the validity of practice guidelines.22 Furthermore, the time during which the proposed recommendations would be valid ought to be defined.23
This entire process is further complicated by the marked increase in number of practice guidelines produced by the various medical societies, a fact that has resulted in a true "Tower of Babel."24 For example, the number of guidelines for clinical practice in cardiology published by the member countries of the ESC has increased exponentially since early 1985, approaching almost 70 by the year 2000.6-8 That same year witnessed the publication of the SEC guidelines, in which the quality, number (39 different guidelines), diversity and breadth of the topics discussed covered virtually all relevant problems in cardiology, arguably making it one of the most important efforts in Europe in this regard. Other societies, in Britain for instance, have developed stable programs for the development of guidelines (National Institute of Clinical Excellence [NICE]) that emphasize the inclusion of cost-effectiveness analyses.25
Not only is it important to develop practice guidelines, it is essential following the drafting process to develop distribution strategies, closing the gap between guidelines and actual practice.9-12 In the US, specific programs have been designed with this purpose, such as the Guidelines Applied in Practice (GAP) project undertaken in Michigan26 and the New England Get With The Guidelines (GWTG) project.27 Among the numerous registries designed by the ESC to determine the present situation within Europe (Euro Heart Surveys),6-8,28 we currently have data from the EUROASPIRE registries,29 which studied in various countries the implementation of the recommendations made in the prevention guidelines.
EDITORIAL POLICY
Due to the rapid increase in medical expertise and the need to minimize overlapping efforts further promoting the quality and consistency of the recommendations, the European Committee for Practice Guidelines was created (www.escardio.org). In order to achieve widespread distribution of the guidelines, the ESC has reached a consensus with the various national societies on the strategy that should govern the publication of these documents in the official journals of each country. The national societies should first approve and endorse the ESC guidelines. The ESC then guarantees exclusive publication rights to the translation of selected guidelines in the official journals of each member country for 6 months after they are first published in the European Heart Journal. This publication should fulfill high quality standards for both the presentation and accuracy of the terms used in the translation, since any document written thereafter should be consistent with the initial official translation.30,31 Since a specific characteristic of the guidelines is the need to adapt to the context in which they will be implemented, the guidelines can include comments or footnotes inserted by local experts that are clearly differentiated from the original document. Consensus regarding the final document is finally reached with the ESC Guidelines Department.
The implications of translating the practice guidelines into Spanish are particularly relevant and probably not comparable to those resulting from any publication done by other ESC member countries. Moreover, the guidelines will be further disseminated to all Spanish-speaking healthcare personnel devoted to the study of cardiovascular diseases worldwide. The systematic process to translate and publish the guidelines by the various ESC member societies has not yet begun, and we can therefore be considered pioneers. Our objective is to publish selected executive summaries of the guidelines directly in Revista Española de Cardiología to facilitate distribution through our electronic edition. Obviously, this presents a new editorial challenge for Revista Española de Cardiología and will require a reorganization of our infrastructure to streamline the translation process and monitor its accuracy, as well as to include specific comments by our experts when appropriate. If we achieve this ambitious objective, our "globalization" effort will have been worthwhile, as we will have contributed to early distribution of the guidelines, and will have promoted interest in their publication through our journal from the scientific point of view.
Scientific knowledge is a necessary, yet not the sole component in good clinical practice. Current medical practice can still be considered an "art" in many important aspects. In the era of evidence-based medicine, this "art" primarily consists of understanding when the individualization of decisions based on clinical reasoning must prevail over the standardization of medical practice.8,32,33 The editors are confident that the publication of the ESC guidelines will help to improve the continuing education and training efforts of Revista Española de Cardiología,34,35 thereby supporting prevention, diagnosis and treatment of cardiovascular diseases.
Correspondence: Revista Española de Cardiología.
Sociedad Española de Cardiología.
Nuestra Señora de Guadalupe, 5-7. 28028 Madrid. España.
E-mail: rec@revespcardiol.org