Analysis of the AUA Guidelines: Strength of Evidence Correlates With Recommendation Levels

Abstract

Introduction:As part of its mission to provide the highest standards of clinical care, the AUA publishes guidelines on numerous urological topics. We sought to evaluate the caliber of evidence used establish the currently available AUA guidelines.Methods:All available AUA guideline statements in 2021 were reviewed for their level of evidence and recommendation strength. Statistical analysis was performed to identify differences between oncological and nononcologic topics, and statements pertinent to diagnosis, treatment, and follow-up. A multivariate analysis was utilized to identify factors associated with strong recommendations.Results:A total of 939 statements across 29 guidelines were analyzed; 39 (4.2%) were backed by Grade A evidence, 188 (20%) Grade B, 297 (31.6%) Grade C, 185 (19.7%) Clinical Principle, and 230 (24.5%) Expert Opinion. There was a significant association of oncology guidelines (6% vs 3%, P = .021) with more grade A evidence and less Grade C Evidence (24% vs 35%, P = .002). Statements pertaining to diagnosis and evaluation were more likely backed by Clinical Principle (31% vs 14% vs 15%, P < .01), treatment statements backed by B (26% vs 13% vs 11%, P < .01) and C (35% vs 30% vs 17%, P < .01) grade evidence, and follow-up statements backed by Expert Opinion (53% vs 23% vs 24%, P < .01). On multivariate analysis, strong recommendations were more likely supported by high-grade evidence (OR = 12, P < .01).Conclusions:The majority of evidence for the AUA guidelines is not high grade. Additional high-quality urological studies are needed to improve evidence based urological care.

Editorial Commentary

“…1 Despite some intrinsic limitations, AUA guidelines certainly provide evidence-based guidance that helps us decide. 2 The current article comes from one of the most laudable statewide quality improvements initiatives in the urology field, the well-known “MUSIC” (for Michigan Urological Surgery Improvement Collaborative) group. 3 In this study, the authors showed the impact of implementing a virtual tumor board (VTB) for the discussion of how to best tackle cases of renal masses.…”

From BPH to male LUTS: a 20-year journey of the EAU guidelines

“…Ultimately, it's what you put into the data blender that determines the quality of the guideline recommendations. In a recent study, it appears that the strength of evidence correlated with recommendation levels [1]. Of 939 statements across 29 AUA guidelines in 2021, the levels of evidence were: Grade A: 39 (4.2%), Grade B: 188 (20%), Grade C: 297 (31.6%), Clinical Principle: 185 (19.7%) and Expert Opinion: 230 (24.5%).…”