Guidelines, position papers and critical reviews: differences and similarities

In the European Journal of Preventive Cardiology more and more position papers and expert consensus papers are published as well as critical reviews. The same is true for the other journals of the European Society of Cardiology (ESC) family, particularly for the European Heart Journal, where all ESC Guidelines are published. A great number of guidelines, position papers and critical reviews have been issued in other different scientific medical journals around the world as well, particularly during the last decades. When searching PubMed under ‘guidelines’ one can find 221,633 papers with the intensity of publication varying from only four in the year 1960 up to 17,625 in the year 2011. One can find also 91,016 ‘critical reviews’, 11,976 ‘position papers’ and 4287 ‘expert consensus papers’. However, many experts are not quite sure what the differences are between these different types of manuscript. This editorial is aimed at providing a brief insight into their differences and similarities. Although focusing only on publications developed/written by the ESC and its entities such as the European Association for Cardiovascular Prevention and Rehabilitation (EACPR), most of this editorial can be applied to the publications of all other scientific societies in medicine as well. Guidelines are official publications of the ESC which are produced by the task forces supervised, reviewed and approved by the ESC Committee for Practice Guidelines (CPG). ESC entities (Associations, Working Groups, Councils, etc.) do not produce their own guidelines but can produce position papers and expert consensus documents in the name of their entity or group of authors. Guidelines are produced to present all the relevant and best available up-to-date evidence on a particular broad clinical issue with the aim to help clinicians in their everyday clinical practice when they have to weigh the benefits and risks of a diagnostic and/or therapeutic procedure. According to this they provide well-balanced information reflecting established evidence-based knowledge on a specific subject and systematically developed recommendations for diagnosis and treatment for practitioners. However, it has to be stressed that applying them in everyday practice always requires careful judgement of individual cases. Considering all this, guidelines are also aimed to be used to develop standards to assess the best clinical practice. The methodological standards for issuing good quality and trustworthy guidelines were well defined more than a decade ago1,2 and ESC Guidelines follow the high quality criteria for the development of guidelines which can be found at www.escardio.org/knowledge/guidelines/rules. Since the guidelines should not only represent the views of one or two specific groups of experts in selected topics, the task forces have to be composed of a diverse expertise to represent the multidisciplinary views and give an objective evaluation of the particular broad subject at hand. The guidelines’ recommendations must be graded according to four different classes (I, IIa, IIb and III) and linked to their levels of evidence (A, B and C), but some guidelines might have in addition also another type of grading such as GRADE (strong or weak recommendation), which could be more suitable for a particular topic and which has the advantage of distinguishing quality of evidence and strength of recommendation.3,4 For instance, this latter type of grading was used in the recently published 2012 joint Guidelines on cardiovascular disease prevention in clinical practice,5 illustrating that strong evidence does not automatically lead to a strong recommendation. Although the implementation of the guidelines’ recommendations should be an integral part of the guidelines’ development process, the adherence to guidelines is often far from optimal due to many barriers which have not substantially changed during the last decade.6–9 Some of the ESC Guidelines are produced solely by the ESC10 and some are produced in partnership with another societies, such as the Guidelines for the management of dyslipidaemias, which were produced jointly with the European Atherosclerosis Society.11 Some ESC Guidelines are the result of collaboration with numerous societies, for example the joint guidelines on cardiovascular disease prevention in clinical practice, which were developed with eight other societies.5 The dissemination of ESC Guidelines is also always accompanied by a number of educational products aimed at helping their implementation. These educational products are their abridged version called pocket guidelines, slide-sets, essential messages, flowcharts, posters, applications for iPhones/iPads/Androids, toolkits, etc. This is different from position papers and expert consensus papers, which have not been accompanied by such derivative products so far. Position papers and expert consensus documents are produced by ESC entities (Associations, Working Groups, Councils), usually by a group of authors appointed by these entities. They reflect the views of these entities, which have also to endorse them. However, they are not necessarily the official opinion of the ESC. There is an agreement that within the ESC no more than two position paper projects should be produced at the same time for a single ESC Working Group but for ESC Associations such a restriction does not exist. Position papers/expert consensus documents can be produced by a single entity or by several in collaboration and even with one or more external societies. These projects first need to be confirmed as not conflicting with the ESC Guidelines Task Forces and an official agreement must exist between ESC and these potential partners. The purpose of position papers/expert consensus documents is to inform clinicians of the opinion of these experts concerning evolving areas of clinical practice and/or technologies that are either recently available but not fully established or are new to the clinical practice community. They can also cover gaps in knowledge and medical practice that should be resolved for an interim period of time, at least until more informative scientific data is made available, which would enable them to be included in official ESC Guidelines. Topics chosen for coverage by position papers/expert consensus documents are often much more specific and detailed that those of the ESC Guidelines. The topic is often subject to considerable ongoing investigations. Thus, the reader should view the position paper/expert consensus document as the best attempt to inform and direct clinical practice in areas where rigorous evidence may not yet be available or data obtained to date is not widely applied to clinical practice. Position papers/expert consensus documents should usually include pros and cons since they have to provide extensive but critical new information. The accessibility of a large volume of information supporting the use of an evidence-based approach is necessary in preparing such a document. If some aspects of the problem are not supported by strong or conclusive related evidence, the process leading to the recommendations must be clearly described. Sometimes position papers/expert consensus documents are produced to address certain topics which are too technical or too specific to be addressed in the official ESC Guidelines. An example of this could be the use of cardiac computed tomography (CT) and myocardial perfusion scintigraphy for risk stratification in asymptomatic individuals without known cardiovascular disease, which was addressed in a position paper produced by the ESC Working Group on nuclear cardiology and cardiac CT.12 Another reason to produce a position paper/expert consensus document could be to address a narrow issue, providing much more detailed information for the experts dealing with exactly this topic than guidelines could provide due to their size restriction and broader approach. A good example of this might be the role of physical activity and exercise in the management of individuals with cardiovascular risk factors, which has been addressed in the joint Guidelines on cardiovascular disease prevention in clinical practice but not in as much depth as in the recently published position paper by EACPR.13 Such a paper can address an issue that has not been addressed previously in a comprehensive way or where no expert consensus existed, as was the case with a recently published EACPR position paper on population-level changes to promote cardiovascular health.14 Formal recommendations spelled out as such, particularly those graded according to different classes and linked to their levels of evidence, are usually not provided in position papers/expert consensus documents as these documents do not have to formally grade the quality of evidence. In some cases they might do this but they have to avoid the wording which is used in the official ESC Guidelines so as to not confuse the end user. However, position papers/expert consensus documents must be in agreement and consistent with the current ESC Guidelines covering the particular clinical topics or, if a major new evidence has emerged after publication of the ESC Guidelines, this has to be clearly stated and referenced. Critical reviews or systematic reviews are usually written by a group of authors who are not appointed by a society or an official body, although such a possibility also exists. They should comprehensively scrutinize the existing medical literature dealing with certain topics aiming at identifying and synthesizing all relevant information.15 An evidence-based approach is essential for drawing conclusions for this type of paper as it is for position papers/expert consensus documents. The data in all published literature must be evaluated for its strengths, weaknesses and validity. A critical review can be comprehensive to various degrees and the time range of material analysed but it usually tries to answer a single clinical question. This is different from the guidelines (but also from the majority of position papers/expert consensus documents), which answer a series of questions in order to help practitioners to make decisions about a range of diagnostic and/or therapeutic interventions. Different databases can be used for literature searching such as PubMed, Medline, Embase, etc. Although similarly to guidelines and position papers/expert consensus documents the prerequisite for data to be included into such a critical review is their high quality and credibility, for this type of paper no restrictions exist that must necessarily be followed when guidelines are produced. Therefore, for example it is not necessary to consider only peer reviewed literature or to avoid abstracts. On the other hand, even in this type of paper, reports that are anecdotal should not be quoted, neither should repetition be made of data from literature which may not stand up to the scrutiny of sound scientific evaluation. In this type of paper the recommendations are not graded according to different classes and linked to their levels of evidence.