Letter: A Bibliometric Analysis of Neurosurgical Practice Guidelines

To the Editor: Clinical practice guidelines (CPG) are “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.”1 They are aimed at improving quality of care by eliminating variation and facilitating the routine application of new advancements.2,3 Even though CPG are widely disseminated, they have shown only a limited effect on physician behavior.4-7 Knowledge regarding the process of changing physician practices in response to published guidelines is limited.8-10 Physician adherences to guidelines may be affected by a variety of factors. A theoretical analysis can help explain the inhibitions before implementation of CPG and possibly help tackle specific problems. In the last several decades the number of neurosurgical articles and guidelines has drastically increased. The development of evidence-based CPG has moved forward toward standardization and improvement of patient care. CPG are created in a pipeline starting with a critical review and evaluation of the published scientific data, which is converted into a set of recommendations that combine both scientific evidence and expert opinion and are therefore considered to describe best practice.11 What are the reasons for the poor adherence to CPG? One of the main obstacles is clinicians’ general feeling of awareness, familiarity, and agreement with the contents. Moreover, physicians are often not confident that they are skilled enough to deliver on the CPG. Clinicians also have to move past the concept of “normal practice” and internalize the idea of change in a dynamic field. Thirdly, physicians and their patients might sometimes have differing aims (or differing from the guidelines). Fourth, multiple external problems involving time, staff, space, equipment, education, and financial resource exist. Such hurdles are crucial and very often lead to difficulties for undeveloped countries to follow CPGs compared to the developed countries, which in most of the cases are those who produced the CPGs. Significant effort has been invested in developing guidelines, and their uptake has been the subject of extensive research.11 Neurosurgeons are not immune from these barriers. Significant efforts are put to produce high-quality evidence-based CPGs but till now there is not a reliable means to evaluate their overall impact on everyday practice.12 Familiarizing us with all the indices and making this first step toward comprehensive analysis of neurosurgical guideline, Lepard and Walters12 push all neurosurgical societies in a way for further development of bibliometric analyses, which will provide a better understanding of treatment options and optimize patients care. Using metric indices, we can evaluate each guideline more precisely regarding results, conclusions, and practical implementation. Although such type of analysis is more difficult and time-consuming rather than estimating publication rate of authors and institutions, it gives more profound and clear understanding of guidelines and could sift out the ones, which are actually unreliable and outdated. Studies evaluating the effects of guideline availability are rare, but make important contributions to the neurosurgical literature and practice. On the other hand, the dissemination of a clinical practice guide does not mean adherence to the clinical practice guide by all means. Deviation from a CPG is not an error if there are good clinical reasons to do so. A physician must always view the CPG as the best recommendation, not considering the individual patients’ risk factors and/or concomitant disease. Every patient has a unique situation, which may deem CPG-inconsistent behavior appropriate. It is impossible to produce a CPG covering every imaginable scenario and nobody expects absolute adherence.11 We strongly support the recommendation that several follow-up studies should be conducted at a predefined time point (eg, 5 yr) after a guideline is produced, in order to evaluate the clinical effects of implementing the guideline.12 Undoubtedly this approach would facilitate the critical review of guideline preparation and presentation. The most valuable tool in assessing the effect of implementing a neurosurgical guideline is the data correlating and conforming to its recommendations and clinical outcome. Bibliometric analyses need to serve as a ground of overall framework, which will be used to measure guideline dissemination and specialty awareness in each neurosurgical field. More research is needed on strategy to improve adherence. Bibliometrics are a step toward right direction for better patient care but are not enough if there is no real impact on the neurosurgical community and ultimately it has an impact on our patients. Disclosures The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.