Invited editorialESPEN disease-specific guideline framework
Introduction
“Medical nutrition” is a novel concept born with the recognition of the importance of malnutrition as a consequence, complication and cause of perpetuation and aggravation of several illnesses. Recent advances and progresses in the non-nutritional management and treatment of different disease states associated with malnutrition highlighted the need for a truly scientific appraisal of nutrition therapy. Indeed, several outcome variables worsened in case of concomitant malnutrition, even when the underlying disease was managed according to the best standards of non-nutritional care. An appropriate nutritional therapy is likely able to improve outcome via the correction or prevention of malnutrition-related complications.1 However, the lack of standardization for the prescription of nutritional solutions for parenteral or enteral or of oral supplementation as well as gaps between prescription and actual clinical practice can explain that the demonstration of improved outcome by appropriate nutritional management is more difficult than initially thought.2, 3 Current practice is sometimes guided by industrial companies and not by scientific societies.
The lack of guidelines in several fields of medicine allows wide variations in daily practice, including the use of non-validated therapeutic modalities. Traditionally, healthcare workers and especially physicians are reluctant to stringent clinical practice guidelines,4 as these are often perceived as limitations to the therapeutic freedom. However, the usual definitions of guidelines do not imply at all any restriction or constraint. The definitions of guidelines range actually from “A general rule, principle, or piece of advice” (New Oxford American Dictionary (2005)) to “systematically develop statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances” (U.S. Institute of Medicine). In some countries, the application of local guidelines is mandatory to get reimbursement of the healthcare costs.
In the field of medical nutrition, the need for unambiguous statements to guide nutrition therapy in well-defined circumstances is enhanced by the involvement of several categories of caregivers (practicing physician of different specialties, nurses, dieticians, pharmacists).1 Furthermore, malnourished patients are often managed by specialists of the underlying disease, without particular skill in nutrition therapy. A recent summary of guidelines applicable to nutrition therapy5 stressed several important points: these clinical practice guidelines are essentially recommendations for the care of patients based on the best available data, but not absolute requirements, nor a substitute for clinical judgment and do not guarantee outcome benefit. Importantly guidelines should be very practical, easily applicable by caregivers and translated in national languages.
An independent evaluation by experts of specific fields with an interest and experience in medical nutrition is mandatory. Professional and international societies of nutrition are by nature committed to this task, in collaboration with specialty societies when applicable. The willingness of ESPEN as a multi-national society is to increase its leadership in guideline development and dissemination, and to increase the professionalism by promoting a systematic and standard approach of the evidence to be translated for clinical practice.6, 7, 8 Several sets of guidelines were published under the auspices of ESPEN, from 1997 to 2009,9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34 but the methodology used for the development of these guidelines was not fully standardized. Collaborations with specialty societies are desirable, to ensure the largest dissemination among specialists in other fields than nutrition.
The ambition of the project of disease-specific guidelines is to review systematically the available data in specific areas and to edict applicable recommendations, based on a standardized and validated evaluation of the available data.35, 36, 38, 39 Areas of uncertainty, when data are lacking, will be addressed by the experts whose personal opinions will be asked. The experts nominated for these tasks are all practicing clinicians working in the field of recommendations. They all have an interest in nutritional issues, even though their main activity may often be related to their primary specialty.
Section snippets
Composition
The Guideline leading committee (GLC) comprises five members: two members designated by the Executive committee (EC) for 4 years, the ESPEN chair, the ESPEN Educational and Clinical Practice committee (ECPC) chair, and a professional methodologist.
Roles
The GLC will define the subjects to be covered by guideline development groups (GDG), name the GDG chairperson and approve the GDG members. It will validate the questions to be addressed by the guideline, define the timeline, monitor the progress and
Guideline process
The development of disease-specific guidelines will follow a standard and systematic methodology. The successive steps have been worked out and adapted from reference guides issued by WHO, SIGN, NICE.35, 36, 38
Budgetary plan
All participation in GLC, GDG will be benevolent, as is the case for all ESPEN committees. The cost of guidelines will include:
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Subsistence allowances of selected persons among GLC, GDG;
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Costs of communication (phone conferences, videoconferences);
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Professional subcontractor for statistical analysis and methodological assistance;
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Access to scientific resources.
Writing the guideline framework
This manuscript was discussed with the ESPEN EC and the ESPEN council in plenary meetings and working group meetings in Nice, France on 14–16 January 2011 and on 6 May 2011. Changes were brought following these discussions.
Conflict of interest statement
Both authors received honoraria for educational presentations during the last 3-year period from Baxter, Danone, Fresenius (JCP); from Abbott, Baxter, B. Braun, Danone, Fresenius, Nestlé, Nutricia (SMS); consultancies were also provided to Abbott, Covidien ans Danone by SMS.
Acknowledgments
JCP and SMS equally contributed to the design and writing of this text.
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