Development of Clinical Practice Guidelines and Primary Care Referral Pathways for the Management of Otorhinolaryngological Conditions in Pakistan

Introduction  Developing region-specific clinical practice guidelines (CPGs) for ear, nose, and throat (ENT) diseases is crucial in Pakistan's primary care, given their significant contribution to clinical cases, aiming to enhance healthcare standards through evidence-based practices with local adaptations.

Objectives  To ensure the standardization of primary healthcare and reduce unnecessary specialist referrals by creating CPGs that are appropriate to our region.

Methods  We selected eight guidelines regarding epistaxis, neck masses, hearing loss, Ménière's disease, dysphonia, allergic rhinitis, acute otitis externa, and rhinosinusitis from the American Academy of Otolaryngology–Head and Neck Surgery Foundation as the source guidelines, and employed the Grading of Recommendations, Assessment, Development, and Evaluation–Adoption, Adaptation, and De Novo Development (GRADE-ADOLOPMENT) approach to contextualize guidelines by adopting, adapting, or excluding recommendations from them. Clinical-referral algorithms were created using recommendations from the CPGs created, with additional recommendations sought through a best-evidence review process.

Results  We developed local CPGs for eight ENT conditions using the GRADE-ADOLOPMENT approach. While most recommendations were adopted in the local CPGs, one recommendation for acute otitis externa, hearing loss, and epistaxis and two for allergic rhinitis were adopted with minor changes. Six recommendations were excluded due to service limitations in Pakistan. Additionally, we created 8 clinical-referral algorithms, incorporating 17 additional recommendations to address gaps in practice, distributed across various conditions.

Conclusion  The newly-established CPGs are instrumental in delivering standardized, high-quality care at the primary care level. Simultaneously, the development of clinical referral pathways empowers general physicians to manage patients effectively and make timely, appropriate referrals to ENT specialists.

Keywords
otolaryngology; referral and consultation; GRADE approach; Pakistan; clinical practice guideline