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P224 Adapting Guidelines with Conflicting Recommendations: The Case of Microscopic Asymptomatic Microhematuria
  1. J Whittaker,
  2. R Loo
  1. Southern California Permanente Medical Group, Pasadena, USA


Background Existing clinical practice guidelines (CPGs) conflict on the best approach to the work-up of patients with asymptomatic microscopic hematuria who are at low risk of urinary tract cancer. Consequently, while adapting existing CPGs to a local context can be an attractive alternative to de novo development, when there are conflicting guidelines, disagreement with recommendations, or missing critical outcomes, potential time and resource gains are often minimised due to the need for additional evidence assessment and stakeholder consensus building activities.

Context To reconcile conflicting recommendations and address gaps in evaluation of critical outcomes, a Guideline Development Team (GDT) in a regional health care organisation used existing CPGs and systematic reviews, supplemented by additional evidence reviews, to develop recommendations for asymptomatic microscopic hematuria.

Description of Best Practice Based on review of evidence synthesised in external guidelines, supplemental de novo evidence reviews on critical outcomes, and risk assessment analysis of patient data, the GDT reached consensus on recommendations that differed from external guidelines, concluding that asymptomatic hematuria patients without risk factors were at sufficiently low-risk for urinary tract cancer to safely eliminate multiphase CT urograms from most urologic evaluations. Guidelines to reduce unnecessary CTs and radiation exposure in low-risk patients were developed, and knowledge transfer interventions aimed at the practitioner and healthcare system levels were implemented.

Lessons for Guideline Developers When adapting external guidelines with conflicting recommendations and gaps in critical outcomes, additional evidence searches, data analysis, and consensus building can negate anticipated gains in time and resources expected from guideline adaptation.

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