https://orcid.org/0000-0003-1186-7104
Adaptation cycle for HIC guidelines.
This editorial refers to ‘Applicability of European Society of Cardiology guidelines according to gross national income’, by W. B. van Dijk et al., https://doi.org/10.1093/eurheartj/ehac606.
Clinical practice guidelines are evidence-based recommendations for the selection of diagnostic tests, procedures, and treatments to improve quality of care and outcomes for patients with cardiovascular disease (CVD).1 The field of cardiology has long been a pioneer in the use of guidelines over several decades now, with widespread adoption and application in many high-income countries (HICs).2 In these settings, adherence to guideline therapies is a key quality-of-care metric and may drive compensation or reimbursement to healthcare providers and hospitals. Regular updates in practice guidelines by well-regarded national and regional cardiovascular societies such as the European Society of Cardiology (ESC), the American College of Cardiology (ACC), and the American Heart Association (AHA) are used to set the global standard of care.
Guideline development is a rigorous process that requires technical expertise, and significant resources. It is often coupled with a well-defined mechanism for regular updates, and dissemination into clinical practice. In low- and middle-income countries (LMICs), the resources for de novo guideline development are often unavailable. Furthermore, the evidence base that is used to make recommendations rarely includes high-quality studies that have been conducted in lower resource settings. Although there have been efforts by the World Health Organization (WHO) to develop global guidelines for CVD, including the Package of Essential Noncommunicable Diseases (PEN) protocols, these guidelines are often quite generic, very limited in their scope, and are not regularly updated to reflect the latest evidence base.3 Thus, in many LMICs, which bear a disproportionately high burden of CVD, the absence of appropriate locally developed guidelines for CVD necessitates the use of available but sometimes ill-suited guidelines from HICs as a substitute for national or regional efforts.
In the study by van Dijk et al. published in this issue of the European Heart Journal, the availability and applicability of 875 guideline recommendations, with 139 attendant specific actions, extracted from their parent ESC guidelines for general cardiology were evaluated.4 These recommendations were disseminated as surveys to 102 ESC national and affiliated cardiac societies, representing almost 80% of the global population. They found that on average, many of the actions (71.6%) were fully available whilst 11.8% of the actions were fully unavailable, independent of the gross national income (GNI). However, in low-income countries (LICs), there was a greater proportion of unavailable actions (29.4%) as compared with HICs (2.4%). In essence, unavailable actions were 10 times more prevalent in LICs. Furthermore, they found that when these actions were mapped back to their parent guidelines, the applicability of those guidelines was also decreased. Their survey data confirmed that recommended actions were often not available due to financial reasons such as a lack of reimbursement of very high costs for hospitals and patients. In many ways, the results of this study validate reasonable assumptions that the ESC guidelines were more directly applicable in HICs such as the ESC member countries as compared with LICs.
There are several reasons for the gaps elucidated by this study. Primarily, there is a need to go beyond mere applicability and/or availability of these recommendations to ask a more fundamental question about adaptability. In other words, are the recommended guideline actions appropriate for the context in which they are being applied? Beyond clinical appropriateness, sociocultural relevance as well as cost-effectiveness in the local practice settings must be considered Traditionally, most clinical practice guidelines developed in HICs have excluded considerations of cost-effectiveness or value, issues that are of critical importance in resource-limited settings.5 Even when cost/value is considered, the accepted benchmark of US$50 000 per quality-adjusted life year for an acceptable cost-effectiveness ratio is out of reach in many low resource settings.6 For instance, the recommended lab-based cardiovascular risk scores including the ESC Score and the Pooled Cohort Equations are often difficult to implement in some LMIC settings where lab testing for serum cholesterol is not readily available due to cost considerations for widespread testing. In these settings, guidance based on non-lab-based risk scores is more appropriate and better implemented, leading the WHO to develop context-specific approaches for HICs and LMICs to prevent complications and undue expenditure.7
To optimize the translation of guideline recommendations from HICs to LMICs, there have been several formal modalities proposed to support guideline adaptation. Owolabi et al. describe an implementation cycle for ‘developing, contextualizing, communicating, and evaluating CVD recommendations for LMICs’. Their proposals include a relevant translatability scale to rank the ease of implementing guideline recommendations. It also includes strategies for engaging key stakeholders iteratively with appropriate feedback and suggests prioritization of high-level guidance where the risk to benefit ratios are clearly defined (Class of Recommendation I and III).8 Other important strategies call for the inclusion of local experts from LMICs in guideline development committees, as well as specific commitments, and financial and technical resources to support the adaptation and implementation of these guidelines in their appropriate settings.9
The impact of clinical practice guidelines in improving the quality of cardiovascular care is incontrovertible. It is time to extend these gains to LMICs through the collaborative, thoughtful, and systematic adaptation and implementation of guideline documents from HICs to the local context. This approach ensures the availability and use of evidence-based, culturally appropriate, cost-effective, and affordable guidelines to improve patient care and cardiovascular outcomes.
Funding
The author declares no funding for this contribution.
References
van Dijk WB, Schuit E, van der Graaf R, Groenwold RHH, Laurijssen S, Casadei B, et al. Applicability of European Society of Cardiology guidelines according to gross national income.
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Author notes
The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.
Conflict of interest: None declared.
