Do AUA Guidelines Stand on the Shoulders of Giants, or Data?
Matthew Moynihan, MD, MPH, Kristian Stensland, MD, MPH
Lahey Hospital and Medical Center, Burlington, MA
BACKGROUND: Urologists and advanced practitioners rely on AUA Guidelines to steer clinical decision making. In an era of evidence based medicine, it could easily be assumed that data exist for all scenarios presented in the guidelines. Understanding the limits of evidential support for the guidelines can aid in interpreting guidelines and identifying areas in which more generation of any level of data is direly needed. We analyzed the AUA Guidelines for reported levels of evidence to identify these gaps in data.
METHODS: All available AUA Clinical Guidelines available from auanet.org were analyzed by two reviewers. Each guideline statementís evidence level was recorded. If a statement had multiple levels of evidence, the higher level was assigned for analysis purposes. In the event of disagreement from reviewers, assignment was made based on consensus. Analyses of data sufficiency were based on statements for which it would be possible for studies to be done and data to be generated, i.e. not "Clinical Principles."
RESULTS: A total of 636 guideline statements from 23 Clinical Guidelines were available. Of these, 516 were not "clinical principles." Most statements were Grade C (207/516 = 40%). Very few statements were Grade A (31/516 = 6%). Nearly a third (155/516 = 30%) of statements were "Expert Opinion," meaning a recommendation was made without sufficient data to even establish an evidence grade. The lowest rates of evidential guideline support were in stress urinary incontinence (12/17 = 70% Expert Opinion), medical therapy for stones (13/23 = 57% Expert Opinion), and localized renal cancer (12/22 = 55% Expert Opinion). There were no Expert Opinion statements for cryptorchidism, prostate cancer detection, or post prostatectomy radiation guidelines.
CONCLUSIONS: Clinicians must understand the studies and data underpinning the AUA Guidelines, particularly as 30% of the guidelines are not based on published evidence. Urologic training should equip urologists to understand and interpret data so that clinicians are able to apply evidence from outside the guidelines to clinical practice. Researchers should also look to the gaps in data support in the guidelines to generate new studies which will provide a stronger foundation to current clinical practices.
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