Guiding Decisions with Evidence Based Tools

Steven N. Kalkanis
Antonia Callas

The CNS established its in-house guidelines program in 2013, in response to growing knowledge gaps within the profession across a wide variety of topics in need of evidence-based decision-making. CNS guidelines serve as an educational tool for the diagnosis, management, and treatment of multiple brain and spine conditions for thousands of neurosurgeons and clinicians across a broad spectrum of disciplines.

In recent years, clinical guidelines and quality measures have become increasingly important as the practice of truly evidence-based medicine has become the standard of care. Guidelines have also proven useful in convincing insurers to pay for a certain procedure based upon the strength of the evidence underpinning a guideline’s clinical practice recommendation, and they have also helped defend physicians against frivolous malpractice claims. Most importantly, we believe that these guidelines efforts across our specialty will promulgate best practices and improve patient outcomes over time, while also highlighting critical unanswered questions in need of further research.

Before the establishment of the CNS guidelines program, approximately one guideline per year was created throughout all of organized neurosurgery. Since the CNS program was launched, production has skyrocketed, with a total of 14 guidelines produced in just three years (Figure 1). These guidelines are then submitted to the Joint Guidelines Committee for ultimate review and endorsement on behalf of our profession.

With 120 physician volunteers on our writing panels and with representation from all our Joint Sections and several other related disciplines, this resource-intensive effort requires more than 40,000 hours of work per year. A diverse, representative panel of authors ensures ownership and the ultimate general acceptance of the recommendations. We believe that multidisciplinary collaboration is critically important since most conditions treated by neurosurgeons also involve other specialists at some point in the patient’s care; accordingly, we have invited authors from a myriad of associations to participate in these guidelines for the benefit of all our patients. These other societies include but are not limited to American Society for Radiation Oncology, Society for Neuro-oncology, American Academy of Neurology, Brain Tumor Foundation, North American Spine Society, American Heart Association, American Stroke Association, and others.

While most guideline projects take, on average, over three years to complete, we endeavor to produce our guidelines in approximately 12 months. We do this because guidelines typically have an average shelf life of five to seven years. Our expedited timeline leads to maximum impact.

The CNS Guidelines Committee takes great care to provide physicians autonomy and flexibility to make a particular treatment recommendation. CNS-produced guidelines strictly adhere to the evidence via a rigorous systematic review process. The CNS Guidelines Committee provides guidance throughout the review process, from the initial proposal through review by the Journal Guidelines Committee (JGC).

Over the next few years, a major focus of the CNS Guidelines team will be to qualitatively and quantitatively assess the impact of these guidelines in clinical practice. We will analyze the extent to which physicians are aware of published guidelines in the literature and how often they are used. Most importantly, we will begin to assess any possible extent of improvement in outcomes for those patients undergoing evidence-based treatments recommended by a particular guideline.

WITH 120 PHYSICIAN VOLUNTEERS ON OUR WRITING PANELS AND WITH REPRESENTATION FROM OUR JOINT SECTIONS AND OTHER RELATED DISCIPLINES, THIS RESOURCE-INTENSE EFFORT REQUIRES MORE THAN 40,000 HOURS OF WORK PER YEAR.