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World Gastroenterology Organisation
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April 2014

WGO Global Guidelines and Cascades

In this month's letter I am highlighting one of the jewels of WGO activities; the Global Guidelines and Cascades.

In putting this letter together I asked the current chair of the Guidelines Committee, Professor Greger Lindberg, to help me by providing the details. His contribution was so good that I decided to use it as written. I thank Greger and wish to acknowledge the wonderful work done by him and his team to the activities of WGO. As you will see from what follows, this is a very active committee.

WGO’s medical practice guideline program is a truly global activity. It all started with a meeting in the Academic Medical Centre (AMC) in The Netherlands in the late nineties. Drs. Justus Krabshuis met the then incoming president of the WGO, Professor GNJ Tytgat, who had a vision…the WGO should and could help Member Societies and colleagues everywhere with producing state of the art guidelines in gastroenterology, endoscopy and hepatology. These guidelines would have to be relevant not just in the ‘West’ but they should be useful everywhere, especially in the more challenged low and middle income (LMIC) countries. Guido Tytgat pushed and encouraged the project and with help from leading topic experts worldwide, a number of guidelines were produced.

Relevance was not the only new aspect. All guidelines were available for free and translated, often by volunteers, in French, Spanish, Mandarin, Portuguese and Russian. Within a few years we saw that more than half of the guideline downloads were in ‘foreign’ languages, not in English. We knew then we were on the right track.

In September of last year, Greger Lindberg had taken over as Chairman for the Global Guidelines Committee after Michael Fried. At the same time Anton LeMair has taken over from Justus Krabshuis as Manager of WGO Guideline Development. Over the years this committee has been very productive and currently has 24 global guidelines that can be downloaded from WGO’s website in six different languages. In 2014 we hope to update Hepatitis B, Dysphagia, Probiotics, and Needle Stick Injury. Timely updates are critical and we focus on guidelines with cascades which are frequently downloaded. The use of WGO Global Guidelines for teaching purposes may need more attention. One possible way to go would be to develop teaching modules for selected guidelines. We will certainly also create new Global Guidelines but numbers will be smaller in the future.

The WGO Guideline Committee aims for a truly global reach. This is achieved by promotion through local Member Societies, translation into six languages, and, above all, the unique resource sensitive cascades for diagnosis and management. The philosophy is to produce easy to read and understand, compact guidelines, which allow for a straightforward communication of practice statements and sharing of knowledge, focusing on clinical implementation.

Effectiveness is very difficult to measure and since the penetrating and almost paradigm-changing ‘Random Reflections on Effectiveness and Efficiency’ of Archie Cochrane (the mould breaking Scottish epidemiologist whose work led to the setting up of the Cochrane Collaboration) we know we need evidence and we know this needs to be based on proper study. From the beginning, Professor Tytgat was well aware of the vital role evidence plays but as a world organization we needed to incorporate not just the gold standard but also we would need to take account of resources available.

The idea of Cascades was born. Later, during the chairmanship of Professor Fried from Zurich, these ideas were formalized into the concept of ‘Cascades’ and it was Michael Fried’s wise tenure of the Guidelines Committee chairmanship that saw guideline production flourish. His vision on Cascades guided the guideline production program for a full eight years before handing over to Professor Lindberg late 2013.

In this period the guideline production flourished …perhaps even too much. As research quickens and more and more results filter down from the bench to the bedside it is vital guidelines are kept up to date. When Professor Lindberg took over he started a major update program, which will ensure all guidelines will be up-to-date and as evidence-based as possible.

Through the Cascades we deliver more than the ‘gold standard’ and compensate for the limitations of strict evidence-based work. We argue that the addition of Cascades to guidelines will increase their impact in large parts of the world. By so doing, we hope to add a new dimension to the ‘knowledge into action’ debate.

A Cascade is a selection of two or more hierarchical diagnostic or therapeutic options, based on proven medical procedures, methods, tools or products for the same disease, condition or diagnosis, aiming to achieve the same outcome and ranked by available resources. Matching options for diagnosis and treatment to available resources can save lives. While the optimal strategy, defined through an evidence-based approach, should always be the goal, one must be aware of the resource limitations that confront our colleagues in certain parts of the world and we should endeavor to work with them in the guideline development process to develop strategies that are clinically sound yet economically feasible and acceptable to their populace.

The Guideline Committee Chair and members form the basis for the guideline program. For each guideline in production, we work with Review Teams with invited experts representing all the regions that make up the diversity among the membership of the society and its target readership. Team members are recruited on a voluntary basis and authorship requires active participation by each of them. For each guideline, a guideline chair heads the Review Team and together they play a crucial role in evaluating the evidence and writing the guideline.

Our approach warrants a relatively short throughput time and cost-effective process. During the guideline production there is no need to meet and everything is done to make best use of experts’ knowledge and time. We propose a balance between evidence and medical practice and, if possible and applicable, resource-based guidelines to take care of access, financial, and technical differences within the user’s communities. The guideline program results in ‘living documents’ that will impact medical practice and increase WGO’s visibility and value, while offering author benefits to the Review Team members and chairs.

WGO Guidelines are constantly reviewed based on a system of monthly literature alerts for each title.

The WGO Guideline library is accompanied by a set of information services to help keep users up to date with the literature and new evidence.

Under the expert guidance of Professors Elewaut and Fevery, WGO's 'Graded Evidence' system is built to help Member Societies of gastroenterology and all those interested in the practice and research of gastroenterology keep track of the literature in topics covered by WGO Guidelines. WGO's Graded Evidence system bridges the gap between new evidence appearing after publication of the guideline and the guideline’s update.

The WGO Ask a Librarian section offers a unique service to members of Member Societies of gastroenterology who do not have easy access to high quality clinical and research information. Professional medical librarians man the ‘Ask a Librarian’ desk and provide support with searching all relevant research clinical literature databases, thus helping to find a simple citation or to perform complex evidence-based gastroenterology literature searches.

Thirdly, the ‘Virtual Room of Gastroenterology' was developed by Professor Spinelli from Argentina and is based on an easy tabular interface with captured PubMed search strategies. The system provides real time access to citations and selected full text for pre-defined medically relevant sub topics for all main gastroenterology fields.

The future for clinical guidelines is bright. More and more evidence will become available, also from LMIC countries, and diagnostic and treatment options will increasingly be able to take account of available resources and epidemiological data.

Increasingly, Member Societies can comment on and influence the relevance of WGO clinical guidelines specifically for their situation and so WGO will be able to ‘customize’ its guidelines for different populations. The more we differentiate the more we fulfill our global mission…and so Member Societies of gastroenterology and WGO outreach meet to make GI care more effective, efficient and relevant locally.


James Toouli
Emeritus Professor of Surgery
President, World Gastroenterology Organisation