Change is inevitable. Charles Kettering, an American inventor and engineer, is known to have said, “the world hates change, yet it is the only thing that has brought progress.” 1 At the American College of Obstetricians and Gynecologists (ACOG), it's time for a change.
Two of the tenets of the ACOG 2020 strategic plan initiated in 2016 were to improve the member experience and to support the obstetrics and gynecology profession. As part of this plan, the ACOG Clinical Content Transformation Initiative was created to address these tenets through enhancing guidance development methodology and quality and revising content formats. Considering that Practice Bulletins have been published since 1998 and Committee Opinions for nearly 30 years, a change was indeed in order, and the ACOG Strategic Plan afforded that opportunity. This initiative was implemented to serve the needs of our members, meet and exceed industry standards in medical guidance development among peer organizations, and enhance ACOG's reputation for developing high-quality clinical guidance. In doing so, we have aligned our guidance-development process with the Institute of Medicine's (now known as the National Academy of Medicine) Trustworthy Guidelines criteria, and we have enhanced transparency and public member input and increased quality control.2
To embark on this initiative, the GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group was consulted as the industry standard for guidance development. Research into other organizations' guidance-development processes, including through the Guidelines International Network, was also considered. Internally, an Evidence-Based Medicine Expert Work Group was created, consisting of ACOG members well-versed and experienced in guidance-development methodology and review, and a methodology expert was contracted. This Initiative evaluated ACOG's resources, including staff and the committee structure, with adjustments made to align with current standards in guidance development and production. These efforts included consolidating assets to facilitate a more resource-intensive process. Committee reconfiguration was implemented to best address the broad range of clinical topics efficiently and to ensure that particular patient groups, such as adolescents, and cross-reaching topics, such as genetics, were considered across all topic development and discussions. Enhanced subspecialty and subpopulation expertise has been distributed among the guidance-development committees to ensure this expertise informs all content development and to allow more comprehensive coverage of issues in one document. This Initiative also necessitated developing new document types to best meet methodologic and design changes and to include coverage of both clinical and advocacy topics.
What does this mean for our readers? The external view will primarily involve a change in the document types and titles. We recognize and appreciate that one of the aspects our members highly value is our clinical guidance as well as advocacy materials and educational resources; we worked to ensure that any format changes were both minimized and essential, to maintain continuity in our approach to presenting clinical content. Thus, although the methodology for content development has been updated and enhanced, the actual layout of the documents will not be drastically different and can easily be assimilated into the members' current process of accessing and reviewing ACOG's content.
The new document types include the following:
Clinical Practice Guidelines. These guidance documents incorporate enhanced methodology for evidence review and synthesis with an adaptation of the GRADE process. The clinical recommendations, intended to optimize patient care, will be determined according to the GRADE process for assessing evidence quality and strength. These documents will be informed by a systematic review of the evidence, including assessment of the benefits and harms of alternative clinical options. The clinical questions for each topic will address the highest priority issues, allowing for efficient content development using a more complex process. Separate articles detailing the methodology will be available in the September 2021 issue of Obstetrics & Gynecology. Clinical Practice Guidelines will be published in Obstetrics & Gynecology.
Clinical Consensus. These guidance documents will focus on narrow, highly significant clinical issues for which evidence may be limited. Comprehensive literature review and evidence analysis are essential components of the development process, although systematic analysis and grading of evidence are not required. This more expeditious approach allows for incorporation of consensus and expert opinion in recommendation development for issues where evidence is limited, with priority on urgent, emerging, and controversial topics. Clinical Consensus documents will be published in Obstetrics & Gynecology.
Committee Statements. These documents will be similar to current Committee Opinions in that they will be developed by specific committees to address issues related to the practice of obstetrics and gynecology, such as ethics and access to care for underserved populations. They are evidence-informed and consensus-based and may include recommendations directed to different audiences, including clinicians, organizations, government agencies, and legislative bodies. Committee Statements will provide guidance about the context and delivery of clinical care and will be published in Obstetrics & Gynecology.
Current clinical documents series that will continue:
Obstetric Care Consensus. The Obstetric Care Consensus series are documents jointly developed with the Society for Maternal-Fetal Medicine (SMFM). The development of these documents will follow similar methodologic processes to the Clinical Consensus series regarding the focus, literature review, and recommendation development, but will also include involvement of authors from SMFM, review by the SMFM Publications Committee, and grading of the recommendations according to the SMFM process.
Position Statements. Position Statements address advocacy issues in the context of clinical care. They provide an urgent response needed on high-visibility issues for members related to obstetrics and gynecology. Position Statements are available on the ACOG website.
Practice Advisories. Practice Advisories serve as clinical guidance relevant to an issue requiring urgent attention, allowing rapid guidance development and dissemination. Practice Advisories will also serve to update existing guidance and will take the place of interim updates to current documents. Issuing Practice Advisories will facilitate the ability to update existing guidance more quickly when indicated. The Practice Advisories will be electronically linked to applicable guidance documents contained in Obstetrics & Gynecology, with content updates prominently displayed. Additionally, readers will be alerted to new Practice Advisories through the monthly ACOG Publications summary page in the journal to further notify readers of guidance updates. Guidance contained in Practice Advisories eventually may be incorporated into Clinical Practice Guidelines and Clinical Consensus documents during development of new documents. Practice Advisories are available electronically at acog.org.
For all ACOG clinical content, a focus on health equity will be incorporated into guidance development and review. Incorporation of health equity incudes a systematic approach, such that heath equity will be considered at each stage of guidance development: health equity expertise on guidance development committees and incorporation of health equity concerns in outline and clinical question development, evidence review and analysis, recommendation development, and document review.
We are pleased to announce this enhanced, methodologic advancement in our clinical guidance. The final Practice Bulletins and Committee Opinions are published in this issue, bringing both series to a close. Additionally, there will be no further Interim Updates; as described above, the Practice Advisories will serve as the venue for providing updates. The Clinical Practice Guideline and Clinical Consensus series will be launched with the first documents published in the September 2021 issue. The Committee Statements will follow soon after. Position Statements and Practice Advisories will continue to be posted on the ACOG website.
Although the launch of the new format is exciting, it is not possible to transition all current Practice Bulletin and Committee Opinion content simultaneously. Current documents will continue to be available until they are replaced or withdrawn, based on the standard review timeline, a process that will involve a transition period of several years. All current clinical guidance, regardless of format, will be available on the ACOG website, through the ACOG Clinical portal (https://www.acog.org/clinical), and on the ACOG app.
An effort of this magnitude takes a village; indeed, this was achievable only with the tireless efforts and dedication of our staff, consultants, and members of the Evidence-Based Medicine Expert Work Group. It is with tremendous gratitude and appreciation that we advance this initiative.
In conclusion, we look forward to an exciting future! It is hard to believe that our current document types have been in existence as long as they have, and that is a testament to the quality and value of ACOG content, which is only going to be further enhanced with this transition. This initiative is designed to meet member needs in both the clinical and advocacy realms, to enhance quality and consistency, and to maintain the excellence for which ACOG is known.
2. Institute of Medicine (US) Committee on Standards for Developing Trustworthy Clinical Practice Guidelines. Graham R, Mancher M, Miller Wolman D, Greenfield S, Steinberg E, editors. Clinical practice guidelines we can trust. The National Academies Press; 2011