Guideline Development Group

Method: Literature Review Procedures

The results of the literature and guideline searches were distributed to the members of the GDG. One member of the group reviewed a list of citations and another member performed a second review of the same list of citations. Articles were included based on whether or not key topics were addressed and the appropriate target populations were included. Case reports and pediatric articles were excluded. The GDG, along with clinicians and academicians who volunteered from both Cardiovascular and Pulmonary and the Acute Care Sections, were invited to review the identified literature.

Reliability of appraisers was established prior to articles being reviewed. Selected articles were reviewed by three individuals who used one of three critical appraisal tools adapted from an evidence based practice textbook to evaluate each according to its type i.e. critical appraisal for studies of prognosis, diagnosis or intervention.¹⁴ The Assessment of Multiple Systematic Review (AMSTAR) tool was used for systematic reviews.¹⁵ Selected diagnosis, prognosis and intervention articles as well as systematic reviews were critically appraised by the GDG to establish test standards. Inter-rater reliability among the four core group members was first established on test articles. Volunteers completed critical appraisals of the test articles to establish inter-rater reliability. Volunteers qualified to be appraisers with agreement of 90% or more. Appraisers were randomly paired to read each of the remaining diagnostic, prognostic or intervention articles. Discrepancies in scoring between the readers were resolved by a member of the GDG.

Clinical practice guidelines were reviewed that fit the scope of this CPG as well as the patient population. Guidelines were included based on whether or not key topics were addressed and the target populations were included. The results of the clinical practice guidelines search were reviewed by one member of the GDG. Four additional clinical expert volunteers underwent training in the Appraisal of Guidelines for Research and Evaluation II (AGREE II)¹⁶ tool to evaluate CPGs with subsequent reliability testing being performed on all reviewers.

Levels of Evidence and Grades of Recommendations

The GDG followed a previously published process on developing physical therapy clinical practice guidelines.¹³ Table 2 lists criteria used to determine the level of evidence associated with each practice statement, with Level I as the highest and Level V as the lowest levels of evidence. Table 3 presents the criteria for the grades assigned to each action statement. The grade reflects the overall and highest levels of evidence available to support the action statement.

Statements that received an A or B grade should be considered as well supported. The clinical practice guideline lists each key action statement followed by rating of level of evidence and grade of the recommendation. Under each statement is a summary providing the supporting evidence and clinical interpretation. The statements are organized in Table 1 according to the action statement number, the statement, and then the key phrase or action statement.