Guideline authors' response to Neurology: Clinical Practice commentary by Drs. Cole and Cascino
AllanKrumholz, Director, US Department of Veterans Affairs Maryland Healthcare System Epilepsy Center of Excellenceguidelines@aan.com
Allan Krumholz, Baltimore, MD; Shlomo Shinnar, Bronx, NY; Jacqueline French, New York, NY; Gary Gronseth, Kansas City, KS; Samuel Wiebe, Calgary, Alberta, Canada
Submitted July 14, 2015
This letter will be co-published by Neurology and Neurology: Clinical Practice
We appreciate Drs. Cole and Cascino's thoughtful comments and provocative insights [1] regarding our recently published first seizure management guideline.[2] We concur that even the American Academy of Neurology's (AAN) rigorous guideline process has limitations, but caution not to make the perfect the enemy of the good.
Practice guidelines are meant to systematically summarize the best evidence relevant to specific clinical questions. Sometimes guidelines can make recommendations that favor one treatment approach over another. [3,4] Practice guidelines are not meant to replace clinical judgment. Rather, guidelines highlight when good judgment is needed because of limitations in the evidence. This guideline, and its earlier companion, [5] review the evidence on reducing short- and long-term seizure recurrence risk, but this may be different from the consequences inherent in a recurrent seizure. This is why the guideline emphasizes the clinician's role in helping patients individually weigh those risks and values. [1] That is the practice of medicine, and guidelines are not supposed to replace it but to inform good clinical decision making. [3,4] AAN guidelines are highly regarded and used by neurologists, [3] and growing access to them on modern digital media make them more available to all medical providers and to patients. This is also good.
1. Cole AJ, Cascino GD. First seizure management: I can see clearly now?
Neurology: Clinical Practice 2015; Neurol Clin Pract 10.1212/CPJ.0000000000000151
2. Krumholz A, Wiebe S, Gronseth GS, et al. Evidence-based guideline:
management of an unprovoked first seizure in adults: report of the Guideline Development Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 2015;84:1705-1713.
3. Gronseth B, French J. Practice parameters and technology assessments:
what they are, what they are not, and why we should care. Neurology 2008;71:1639-1643.
4. Ben-Menachem E, French JA. Guidelines -- Are they useful?
Epilepsia 2006;47 Suppl 1:62-64.
5. Krumholz A, Wiebe S, Gronseth G, et al. Practice parameter:
evaluating an apparent unprovoked first seizure in adults (an evidence- based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 2007;69:1996-2007.
For disclosures, contact the editorial office at journal@neurology.org.
We appreciate Drs. Cole and Cascino's thoughtful comments and provocative insights [1] regarding our recently published first seizure management guideline.[2] We concur that even the American Academy of Neurology's (AAN) rigorous guideline process has limitations, but caution not to make the perfect the enemy of the good.
Practice guidelines are meant to systematically summarize the best evidence relevant to specific clinical questions. Sometimes guidelines can make recommendations that favor one treatment approach over another. [3,4] Practice guidelines are not meant to replace clinical judgment. Rather, guidelines highlight when good judgment is needed because of limitations in the evidence. This guideline, and its earlier companion, [5] review the evidence on reducing short- and long-term seizure recurrence risk, but this may be different from the consequences inherent in a recurrent seizure. This is why the guideline emphasizes the clinician's role in helping patients individually weigh those risks and values. [1] That is the practice of medicine, and guidelines are not supposed to replace it but to inform good clinical decision making. [3,4] AAN guidelines are highly regarded and used by neurologists, [3] and growing access to them on modern digital media make them more available to all medical providers and to patients. This is also good.
1. Cole AJ, Cascino GD. First seizure management: I can see clearly now? Neurology: Clinical Practice 2015; Neurol Clin Pract 10.1212/CPJ.0000000000000151
2. Krumholz A, Wiebe S, Gronseth GS, et al. Evidence-based guideline: management of an unprovoked first seizure in adults: report of the Guideline Development Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 2015;84:1705-1713.
3. Gronseth B, French J. Practice parameters and technology assessments: what they are, what they are not, and why we should care. Neurology 2008;71:1639-1643.
4. Ben-Menachem E, French JA. Guidelines -- Are they useful? Epilepsia 2006;47 Suppl 1:62-64.
5. Krumholz A, Wiebe S, Gronseth G, et al. Practice parameter: evaluating an apparent unprovoked first seizure in adults (an evidence- based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 2007;69:1996-2007.
For disclosures, contact the editorial office at journal@neurology.org.