CHEST’s clinical guidelines are highly regarded and relied-upon recommendations that help clinicians enrich patient care and improve health outcomes worldwide. However, the rigorous process by which these guidelines are identified, submitted, and refined can be confusing.

During CHEST 2024, experienced guideline participants reviewed key steps and shared insights during the session, Guideline Development at CHEST for Beginners and Experts.

Identifying pivotal topics

Akram Khan, MD, FCCP, Associate Professor of Medicine at Oregon Health & Science University, described how to choose an appropriate topic for guideline development.

“You want to propose topics that are important to the constituency of CHEST and directly apply to a lot of members,” he said. “It should have a high impact, which could be in public health or patient care, or some kind of an economic impact. Often, guidelines are done in areas where there is a lot of practice variability or something new has come up, which an average practicing physician may not have an idea how best to apply to their practice.”

When identifying pivotal clinical topics, Dr. Khan suggested considering the following areas: high clinical variability, complex decision-making, rapidly evolving evidence, preventive care, rare or complex disorders, interdisciplinary care, public health, ethical dilemmas, medication safety, and cost-effectiveness.

Dr. Khan offered advice on how to improve the chances of success with submission. The topic should align with the mission and vision of CHEST guidelines and have clear goals and objectives. The focus should be on areas where there is a lack of ongoing or existing guidelines. The guideline panel should represent CHEST’s commitment to inclusivity. The topic should be able to be completed in 18 to 24 months, and it should include clear questions based on the population, intervention, comparison, and outcome (PICO) format.

From idea to publication

Angel Coz, MD, FCCP, Professor of Medicine at Cleveland Clinic Lerner College of Medicine,​ discussed the process of guideline development.

“We create the questions based on the clinical needs of what the clinician at the bedside is asking, and then we look for the evidence to try and answer that question,” Dr. Coz said.  

Submitting guidelines to CHEST involves a multistep process. The first step involves a preliminary topic proposal. The guidelines committee reviews and prioritizes these proposals and asks those who meet a need to develop a whole guideline proposal.

The focus of the guideline development then shifts to critical outcomes, since those will determine the strength of the recommendation. Following a search of the literature, participants select which articles will go to the meta-analysis.

Next, the guideline panel evaluates the evidence in order to develop final recommendations. The framework for this process looks at the benefits and harms of the options, values and balance of effects, resources required, cost-effectiveness, equity, acceptability, and feasibility. This leads into the drafting of a manuscript and, finally, publication.

Picking the team

Israa Soghier, MD, MS, CHEST Guideline Methodologist and Assistant Professor of Medicine at New York University, offered tips for selecting a guideline panel.

Starting early is important, Dr. Soghier said, since CHEST expects a preliminary panel at the full proposal submission phase. Submitters should consider diversity, equity, and inclusion criteria, as well as the ability of panelists to collaborate effectively with each other in their respective roles.

“You also want to think about your individual PICO questions,” she said. “You want to have experts with that specific PICO expertise, and it’s nice if they have prior guideline participation. You want to pick people with opposing views. You don’t want to have intellectual biases.”

Encourage potential panelists to take a look at the CHEST relationship policy, Dr. Soghier said. It’s a good idea to have a backup plan in case any panelists are ineligible to participate for any reason, including conflicts of interest.

The National Academy of Medicine defines conflicts of interest as circumstances that create a risk that professional judgments or actions regarding a primary interest will be unduly influenced by a secondary interest. There are different types of conflict of interest, including financial, intellectual, and personal/religious/political.

All panel members should disclose their conflicts of interest prior to becoming panelists, before taking on new relationships, and during guideline development. The CHEST Professional Standards Committee manages conflicts of interest.