Tuesday, 12 July 2016

Evidence, guidelines and possible solutions

I was looking at the guidelines on the management of community acquired pneumonia (CAP) in adults: This got me interested into looking at the BTS guidelines update 2009 ( ).

Here are some observations and thoughts on it.

The 2009 British guidelines for pneumonia in adults:

Has 12 Authors W S Lim, S V Baudouin, R C George, A T Hill, C Jamieson, I Le Jeune, J T Macfarlane, R C Read, H J Roberts, M L Levy, M Wani, M A Woodhead

Endorsed by 10 major clinical professional societies British Thoracic Society Standards of Care Committee in collaboration with and endorsed by the Royal College of Physicians of London, Royal College of General Practitioners, College of Emergency Medicine, British Geriatrics Society, British Infection Society, British Society for Antimicrobial Chemotherapy, General Practice Airways Group, Health Protection Agency, Intensive Care Society and Society for Acute Medicine

502 references

45 pages of guidelines, 6 pages for the synopsis of the guidelines

Giving us 137 specific guidelines for management of CAP in adults.

Very extensive and formidable work. Would not have been easy to do and
must have consumed a lot of time and other resources.

The evidence was classified as ABCD. You know all about it but I detail
here for the purpose of my own clarity.

A+ A good recent systematic review of studies designed to answer the
question of interest

A - One or more rigorous studies designed to answer the question, but
not formally combined

B+ One or more prospective clinical studies which illuminate, but do not
rigorously answer, the question

B - One or more retrospective clinical studies which illuminate, but do
not rigorously answer, the question

C Formal combination of expert views

D Other information

BTS guidelines' recommendations are based on the following evidence levels:

4 A+ evidence recommendations (3%)
8 A- recommendations (5%)
19 B+ recommendations (17 + 2 : some recommendations have some
sub-sections with different levels of evidence) (13%)
6 B - recommendations (4 + 2 : some recommendations have some
sub-sections with different levels of evidence) (4%)
19 C recommendations (13%)
91 level D recommendations (62%)

147 evidence points resulting in 137 recommendations

My commentary

It looks like an overwhelming majority of recommendations are based on level C and D evidence which in my mind translates basically as 'individuals' opinions'. To put it radically, level C and D 'evidence' is mere opinion masquerading as evidence just because it comes in a list where the level A is properly scientific.

Whom would I trust for my own care, if I had pneumonia? I would trust our own local clinicians' opinions more as it will have local and personal context than someone who has published (guidelines comprising of 75% opinion) but has no bearing on who we are and what we do. Even the 25% level B recommendations are according to the definition 'do not rigorously answer the question'. If I had CAP why would I want my clinical treatment based on recommendations that do not rigorously
answer the question combined with the opinion of non-local physicians?


The way forward would be groups of local clinicians agreeing on local delivery protocols based on their personal local knowledge, context and resources. Once agreed, the outcomes of the delivery can be tracked and the protocols continuously improved. We know this approach reaches us a better place than externally mandated approaches.

This blog site has outlined some ideas on this approaches which can be found at:

There are significant unresolved issues on the question of evidence based practice. They need to be dealt with by the Quality Improvement approaches. Let us do it.


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