American Urological Association guidelines marked by rigorous reviews, timely updates

The AUA is taking a number of steps to ensure that its clinical practice guidelines are scientifically rigorous and timely. In this interview, J. Stuart Wolf, Jr, MD, chair of the AUA Practice Guidelines Committee, discusses those steps, the value of clinical guidelines, and the challenge of disseminating and implementing them. Dr. Wolf is professor of urology, director of the division of endourology, and associate chair for clinical operations at the University of Michigan, Ann Arbor. He was interviewed by Urology Times Editorial Consultant Stephen Y. Nakada, MD, professor and chairman of urology at the University of Wisconsin, Madison.

Q Please start by telling us what the AUA clinical practice guidelines are.

Q Take us through the process of creating a clinical guideline.

A It's a very rigorous nine-step process that we've been instituting for about 2 years now. I won't go through every step, but let's review a few highlights. We first very carefully identify the topic, which is usually nominated by an AUA member. The criteria we look at when selecting a topic are the problem or condition being common, being pertinent to domestic practice, and one in which there is significant variability in practice.

These criteria speak to the goals of the guidelines, which are to assist as many practitioners and as many patients as possible and to reduce variation of care. You and I know that some variation in care is quite appropriate. If a man presents with an unusual renal cancer or if a woman has an unusual presentation of a urinary tract infection, then such a patient could be managed "outside standard practice." But we both also know that there's a lot of inappropriate variation in urologic care in this country, and guidelines can help reduce that. All of the steps in the process of guideline creation are important, of course, but other steps that should be highlighted include the utilization of an objective systemic review and explicit level-of-evidence rating to create the evidence report, the panel's creation of well-defined guidelines statements that are explicitly linked to the certainty of the evidence, and the extensive review of the draft document by urologists and other stakeholders that often leads to important revisions in the guideline.

Q How are the guidelines updated?