By Ian Windmill and Valentina Such

Academy’s Clinical Practice Guidelines: Brief History and Impact

In July 2022, the American Academy of Audiology marked the 30th anniversary of the first publication of its clinical practice guideline. Since then, the Academy, powered by a sense of urgency to translate research evidence into clinical practice to guide the field of audiology, has developed a number of clinical practice guidelines and guidance documents across the spectrum of audiology and hearing-loss disorders. 

Clinical practice guidelines have become prominent in clinical medicine over the last several decades and represent one of the most important tools for improving clinical decision-making and patient care and outcomes. As defined by the National Academy of Medicine (formerly, the Institute of Medicine; 2011), clinical guidelines are “statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options,” which, along with clinical judgment and experience, help clinicians provide the best patient care possible. In addition, these documents are developed to support health-care policy and advocacy, improve quality of care and cost-effectiveness of interventions, decrease variations in clinical practice, and identify pertinent research directions (Woolf et al, 1999).

Following the publication of the 2011 Institute of Medicine report on standards regarding the development of trustworthy clinical practice guidelines, including eight pillars—transparency, management of conflict of interest, guideline development group composition, clinical practice guideline–systematic review intersection, establishing evidence foundations for and rating strength of recommendations, articulation of recommendations, external review, and updating—a number of important developments involving clinical practice guidelines have emerged (Murad, 2017). 

The guideline developers and researchers have produced extensive guidance on how to develop implementable high-quality guidelines. Such resources include, but are not limited to, the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument; Guidelines International Network (G-I-N) Standards for Clinical Practice Guidelines; Grading of Recommendations Assessment, Development and Evaluation (GRADE) system; RAND/UCLA Appropriateness Method; and the Guideline Implementation Tools Framework (Kredo et al, 2016; Shekelle, 2018). The American Academy of Audiology (2019), in turn, developed and published its Guideline for Guidelines to publicly and transparently declare the standards by which the Academy develops clinical practice documents and continues to review, identify, and implement development process improvements.  

Given how important clinical practice guidelines and strategic documents and statements are to the field of audiology, the Guidelines and Strategic Documents Committee, in support of the Academy’s mission to promote quality hearing and balance care through education, research, and increased public awareness, has been managing and overseeing the process for developing and endorsing clinical practice documents, with input from the Academy’s members, the Scientific Advisory and Research Council, and the Board of Directors. The development and implementation of guidelines for audiologists is a rigorous process that involves multiple stakeholders to ensure that the guidelines reflect the changing clinical science and meet the needs of practicing audiologists. By evaluating and reviewing the knowledge base, identifying gaps in practice, and following best practices for guideline development, the Academy is creating change in patient care and audiology practice through clinical guidelines. 

Academy’s Clinical Practice Documents: Summary of Developments 

To keep pace with evolving evidence, new guidelines are created and published guidelines are periodically revised. Full-guideline revisions occur approximately every 5 or more years, but individual recommendations may be reviewed annually based on significant new research. Ancillary to guidelines, the Academy develops guidance statements, clinical consensus documents, and position statements, which provide expert opinion and evidence summaries on important topics that are narrow or immature to warrant a full guideline but for which there is significant scientific and clinical interest.

Clinical Document Review for Currency and Prioritization for Assessment and Revision

The Guidelines and Strategic Documents Committee has developed a formal process to assess currency of the Academy’s published documents and to prioritize document topics for update or development considering the following criteria: new published evidence, policy changes from federal regulatory bodies, document topic addressing a condition that is associated with a significant morbidity, widespread variation in practice, and timeliness. 

Clinical document priorities approved in 2022 include revision of the Standards of Practice for Audiology and Scope of Practice, systematic review on health-related quality of life and hearing aids, and guidelines on audiological management of adult hearing impairments and on diagnosis and management of tinnitus. Also approved is the development of new documents on the topics of comprehensive hearing evaluation in adults, assessment of vestibular function in the pediatric population, diagnosis and treatment of vestibular disorders, and untreated hearing loss linked to depression and social isolation, as well as the development of educational resources, algorithms, and health-care tools. To view the Academy’s current library of guidelines and strategic documents and a list of guidelines in development, please visit the Academy’s Practice Resources website. 

Opportunities to Volunteer and Make an Impact

As the Academy continually creates new clinical practice documents and updates existing documents, the audiologists should be actively engaged in this process to help foster stakeholder buy-in thereby improving adherence to guidelines and best practices. To realize the Academy’s vision to advance the science, practice, and accessibility of hearing and balance health care for our patients, we must do this work together. There are many ways you can share your time and expertise—contributing as writing committee chairs or members, methodologists, peer reviewers, public comment participants, content expert reviewers for guideline endorsement consideration. Volunteer by completing an online application and play an integral role in helping to deliver on the mission and promote the highest-quality patient care.

Endorsement Policy and Process

In 2022, the Academy’s Board of Directors approved a policy and a set of procedures for endorsing clinical practice documents developed by other professional organizations. Endorsement efforts are intended to reduce duplication of effort and to present harmonized recommendations across health professional organizations involved in development of clinical documents for management of patients with hearing and balance disorders. The American Academy of Audiology will consider endorsement either upon request from peer professional organizations or when the Academy seeks to endorse another organization’s guideline in lieu of undertaking its own on the same topic. The full process is articulated in the American Academy of Audiology Endorsement of Clinical Practice Documents Developed by External Organizations policy document. Please also be sure to check Clinical Practice Guideline: Tympanostomy Tubes in Children (Update) developed by the American Academy of Otolaryngology–Head and Neck Surgery (Rosenfeld et al, 2022), American Cochlear Implant Alliance Task Force Guidelines for Determining Cochlear Implant Candidacy in Children (Warner-Czyz et al, 2022), and American Cochlear Implant Alliance Task Force Guidelines for Clinical Assessment and Management of Cochlear Implantation in Children With Single-Sided Deafness (Park et al, 2022) that were endorsed by the American Academy of Audiology.

Practice Guidelines and Standards Website Redesign

At the organizational level, the Academy continues to develop and improve electronic platforms and applications to facilitate access to and dissemination of guidelines and recommendations. The Academy has initiated the Practice Guidelines and Standards website update to enhance member experience and access to the latest guidance and resources. Enhancements will include ability to browse by year of publication and document topic, listing of the document status (Current, Reaffirmed, Retired, Endorsed, Affirmed, In Revision), document type, summary and key points, tools and educational derivatives, related content. Having improved clinical document website as the hub of clinical practice content and tools with continued consistent maintenance will ensure the ongoing integrity of clinical document resources. September–October 2022 is targeted for deployment of the redesigned website. 

Conclusion and Future Directions

Ongoing goals of the Academy in the area of clinical practice document development include improvements to the dissemination and implementation of practice guidelines and continued collaboration with other organizations on joint documents. Clinical practice guideline recommendations remain the primary source of guidance for clinicians. Access to recommendations should be enhanced through sources other than the full versions of the guidelines, including access via smartphone applications and various digital platforms. Moving toward “living” documents (Akl et al, 2017) should be evaluated and options considered. However, most important is to maintain the steadfast commitment to the development and dissemination of clinical practice guidelines based on a rigorous, unbiased evaluation of evidence combined with a focus on patient-centered care and shared decision-making. 

This article is a part of the September/October 2022 Audiology Today issue.

References

Akl EA, Meerpohl JJ, Elliott J, Kahale LA, Schünemann HJ, Living Systematic Review Network. (2017) Living systematic reviews: 4. Living guideline recommendations. J Clin Epidemiol 91(November):47–53.

American Academy of Audiology. (1992) Audiologic guidelines for the diagnosis and treatment of otitis media in children. Audiol Today (July/August). staging.audiology.org/practice-resources/practice-guidelines-and-standards/audiologic-guidelines-for-the-diagnosis-and-treatment-of-otitis-media-in-children (accessed July 20, 2022).

American Academy of Audiology. (2019) The American Academy of Audiology clinical practice guidelines development process. staging.audiology.org/practice-resources/practice-guidelines-and-standards/clinical-practice-guidelines-development-process (accessed July 20, 2022).

American Academy of Audiology. (2022) American Academy of Audiology endorsement of clinical practice documents developed by external organizations. staging.audiology.org/practice-resources/practice-guidelines-and-standards/american-academy-of-audiology-endorsement-of-clinical-practice-documents-developed-by-external-organizations (accessed July 25, 2022).

American Academy of Audiology. (2022) Practice guidelines and standards. https://staging.audiology.org/practice-resources/practice-guidelines-and-standards/ (accessed July 20, 2022). 

Institute of Medicine (US) Committee on Standards for Developing Trustworthy Clinical Practice Guidelines. (2011) Clinical Practice Guidelines We Can Trust. National Academies Press: Washington, DC. 

Kredo T, Bernhardsson S, Machingaidze S et al. (2016) Guide to clinical practice guidelines: the current state of play. Int J Qual Health Care 28(1):122–128.

Murad MH. (2017) Clinical practice guidelines: a primer on development and dissemination. Mayo Clin Proc 92(3):423–433.

Park LR, Griffin AM, Sladen DP, Neumann S, Young NM. (2022) American Cochlear Implant Alliance Task Force guidelines for clinical assessment and management of cochlear implantation in children with single-sided deafness. Ear Hear 43(2):255–267.

Rosenfeld RM, Tunkel DE, Schwartz SR et al. (2022) Clinical practice guideline: tympanostomy tubes in children (update). Otolaryngol Head Neck Surg 166(Suppl. 1):S1–S55.

Shekelle PG. (2018) Clinical practice guidelines: what’s next? JAMA 320(8):757–758.

Warner-Czyz AD, Roland JT Jr, Thomas D, Uhler K, Zombek L. (2022) American Cochlear Implant Alliance Task Force guidelines for determining cochlear implant candidacy in children. Ear Hear 43(2):268–282.

Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. (1999) Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. BMJ 318(7182):527–530.

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