Assumptions of the Writing Panel
Before these Appropriate Use Criteria are consulted, it is assumed that:
- Patient history, physical examination, and/or imaging are consistent with diagnosis of complete anterior cruciate ligament (ACL) tear.
- Patient has primary ACL tear, not a recurrent tear.
- Patient does not have significant multi-ligament injuries (grade 1-2 medial collateral ligament injuries are not exclusions).
- Patient is otherwise in good health and good candidate for surgery.
- Patient does not have a periarticular knee fracture.
- The surgeon is trained and capable of performing all operative techniques with equal effectiveness.
- Patient is able to participate and/or cooperate in physical therapy or rehabilitation.
- The physician has an informed discussion with the patient about the treatment options and that the optimum treatment options may change over time for the patient. Before operative intervention is recommended, the appropriateness and potential efficacy of non-operative intervention has been considered.
- Before a patient undergoes surgery they have achieved good quad control, have minimal effusion, and good range of motion. If not, surgery will be postponed until this occurs.
- The surgeon will perform the surgery in the most appropriate location (i.e., ambulatory surgery center [ASC], outpatient, inpatient) based on the health of the patient and associated injuries.
- The facility has each type of implant/equipment available and capable support personnel.
- Regarding graft choices: neither bone nor patellar tendon should be placed across the physes.
- A failed optimal nonoperative measure is defined as: patient has received optimal care and has received symptoms of recurrent instability. Nonoperative measures include: bracing, activity modification, and rehabilitation/physical therapy.
- Arthritic changes discussed in these Appropriate Use Criteria are assumed to be from osteoarthritis or post traumatic arthritis and exclude inflammatory arthropathies.
- Arthritic changes in patients with open physes were removed due to clinical rarity.
Results of Appropriateness Rating
The Appropriate Use Criteria tables (see pages 19-28 in the original guideline document) contain the final appropriateness ratings assigned by the ten members of the voting panel. Patient characteristics are found under the column titled "Scenario". The Appropriate Use Criteria for each patient scenario can be found within each of the 10 treatment rows. These criteria are formatted by appropriateness labels (i.e., "R"=Rarely Appropriate, "M"=May Be Appropriate, and "A"=Appropriate), median rating, and + or - indicating agreement or disagreement amongst the voting panel, respectively.
Anterior cruciate ligament (ACL) injuries
Note: The following conditions are not covered by this Appropriate Use Criteria:
- Tibial eminence fracture
- Additional ligament injuries beyond an incomplete medial collateral ligament (MCL) injury
- Re-tears of prior reconstructions
- Partial ACL injuries
Physical Medicine and Rehabilitation
- To help determine the appropriateness of clinical practice guideline recommendations for the heterogeneous patient population routinely seen in practice
- To determine the appropriate criteria for treatment of anterior cruciate ligament injuries in order to improve patient care and obtain the best outcomes while considering the subtleties and distinctions necessary in making clinical decisions
Skeletally immature and skeletally mature patients who have been diagnosed with an anterior cruciate ligament (ACL) injury of the knee
- Self-directed exercise program without reconstruction
- Supervised rehabilitation program without reconstruction
- Activity modification without reconstruction
- Anterior cruciate ligament (ACL) functional knee brace without reconstruction
- ACL reconstruction
- Physeal-sparing autograft
- Physeal-sparing allograft
- Transphyseal-sparing autograft
- Transphyseal-sparing allograft
- Patient satisfaction
- Knee laxity
- Knee range of motion (ROM)
- Activity levels
- Weight bearing
- Functional scores
- Graft failure rates
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Concurrent with the writing panel developing the criteria, the American Academy of Orthopaedic Surgeons (AAOS) Evidence-Based Medicine Unit undertook a literature review based on the results of the 2014 AAOS Clinical Practice Guideline on Treatment of Anterior Cruciate Ligament Injuries (see the "Availability of Companion Documents" field) and all literature published after the release of the clinical practice guideline related to the treatment of anterior cruciate ligament injuries. This literature review informed the decisions relevant to the indications identified by the writing panel when they were available and necessary. The literature review also considered lower quality evidence when the best available evidence (i.e., randomized control trials) did not contain information relevant to the clinical scenarios.
The search terms used and the inclusion and exclusion criteria can be found in the Methodology section of the clinical practice guideline on the same topic (see the National Guideline Clearinghouse [NGC] summary of the American Academy of Orthopaedic Surgeons clinical guideline on management of anterior cruciate ligament injuries).
156 articles were included after full text review and quality analysis in the clinical practice guideline. All literature published after the release of the clinical practice guideline was also reviewed.
Weighting According to a Rating Scheme (Scheme Given)
For information on how the quality of data was evaluated, see the National Guideline Clearinghouse (NGC) summary of the American Academy of Orthopaedic Surgeons (AAOS) guideline American Academy of Orthopaedic Surgeons clinical practice guideline on management of anterior cruciate ligament injuries.
Systematic Review with Evidence Tables
The purpose of this Appropriate Use Criteria (AUC) is to help determine the appropriateness of clinical practice guideline recommendations for the heterogeneous patient population routinely seen in practice. The best available scientific evidence is synthesized with collective expert opinion on topics where gold standard randomized clinical trials are not available or are inadequately detailed for identifying distinct patient types. When there is evidence corroborated by consensus that expected benefits substantially outweigh potential risks, exclusive of cost, a procedure is determined to be appropriate. The American Academy of Orthopaedic Surgeons (AAOS) uses the Research and Development/University of California, Los Angeles (RAND/UCLA) Appropriateness Method (RAM). The process includes these steps: reviewing the results of the evidence analysis, compiling a list of clinical vignettes, and having an expert panel comprised of representatives from multiple medical specialties to determine the appropriateness of each of the clinical indications for treatment as 'Appropriate,' 'May be Appropriate,' or 'Rarely Appropriate.'
Expert Consensus (Delphi)
The American Academy of Orthopaedic Surgeons (AAOS) uses the Research and Development/University of California, Los Angeles (RAND/UCLA) Appropriateness Method (RAM).
Two panels participated in the development of the AAOS AUC for Treatment of Anterior Cruciate Ligament Injuries. Members of the writing panel developed a list of over 350 patient scenarios, for which 10 treatments were evaluated for appropriateness. The voting panel participated in two rounds of voting. During the first round of voting, the voting panel was given approximately one month to independently rate the appropriateness of each the provided treatments for each of the relevant patient scenarios as 'Appropriate', 'May Be Appropriate', or 'Rarely Appropriate' via an electronic ballot. After the first round of appropriateness ratings were submitted, AAOS staff calculated the median ratings for each patient scenario and specific treatment. An in-person voting panel meeting was held in Rosemont, IL on April 25th of 2015. During this meeting, voting panel members addressed the scenarios/treatments which resulted in disagreement (definition of disagreement can be found in Table 3 in the original guideline document). The voting panel members were asked to rerate their first round ratings during and after the voting panel meeting, only if they were persuaded to do so by the discussion and available evidence. Voting occurred during the in-person meeting and continued for approximately one week following the meeting. The voting panel determined appropriateness by rating scenarios (i.e. criteria) as 'Appropriate', 'May Be Appropriate', or 'Rarely Appropriate'. There was no attempt to obtain consensus about appropriateness.
Members of the AUC for Treatment of Anterior Cruciate Ligament Injuries writing panel, who are orthopaedic specialists in treating knee-related injuries/diseases, developed clinical scenarios using the following guiding principles:
- Patient scenarios must include a broad spectrum of patients that may be eligible for treatment of anterior cruciate ligament injuries [comprehensive]
- Patient indications must classify patients into a unique scenario [mutually exclusive]
- Patient indications must consistently classify similar patients into the same scenario [reliable, valid indicators]
The writing panel developed the scenarios by categorizing patients in terms of indications evident during the clinical decision making process (see Figure 1 in the original guideline document). These scenarios relied upon definitions and general assumptions, mutually agreed upon by the writing panel during the development of the scenarios. These definitions and assumptions were necessary to provide consistency in the interpretation of the clinical scenarios among experts voting on the scenarios and readers using the final criteria.
Formulating Indications and Scenarios
The AUC writing panel began the development of the scenarios by identifying clinical indications typical of patients commonly presenting with anterior cruciate ligament injuries in clinical practice. Indications are most often parameters observable by the clinician, including symptoms or results of diagnostic tests. Additionally, "human factor" (e.g., activity level) or demographic variables can be considered.
Indications identified in clinical trials (derived from patient selection criteria) included in AAOS Clinical Practice Guidelines (CPGs) served as a starting point for the writing panel and ensured that these AUC referred to the evidence base for the treatment of anterior cruciate ligament injuries CPG. The writing panel considered this initial list and other indications based on their clinical expertise and selected the most clinically relevant indications (see Table 4 in the original guideline document). The writing panel then defined distinct classes for each indication in order to stratify/categorize the indication (see Table 4 in the original guideline document).
The writing panel organized these indications into a matrix of clinical scenarios that addressed all combinations of the classifications. The writing panel was given the opportunity to remove any scenarios that rarely occur in clinical practice, but agreed that all scenarios were clinically relevant. The major clinical decision making indications chosen by the writing panel divided the matrix of clinical scenarios into chapters, as follows: age/maturity level, activity level, presence of advanced arthritis, presence of reparable meniscus tear, and prior failure of nonoperative measures (see Table 4 in the original guideline document).
Creating Definitions and Assumptions
The AUC for Treatment of Anterior Cruciate Ligament Injuries writing panel constructed concise and explicit definitions for the indications and classifications. This standardization helped ensure the way that the writing panel defined the patient indications was consistent among those reading the clinical scenario matrix or the final criteria. Definitions drew explicit boundaries when possible and were based on standard medical practice or existing literature.
Additionally, the writing panel formulated a list of general assumptions in order to provide more consistent interpretations of a scenario (see Assumptions of the Writing Panel in the "Major Recommendations" field). These assumptions differed from definitions in that they identified circumstances that exist outside of the control of the clinical decision making process.
Assumptions also addressed the use of existing published literature regarding the effectiveness of treatment and/or the procedural skill level of physicians. Additionally, assumptions highlighted intrinsic methods described in this document such as the role of cost considerations in rating appropriateness or the validity of the definition of appropriateness. The main goal of assumptions was to focus scenarios so that they apply to the average patient presenting to an average physician at an average facility.
The definitions and assumptions should provide all readers with a common starting point in interpreting the clinical scenarios. This list of definitions and assumptions accompanied the matrix of clinical scenarios in all stages of the development of this AUC and appears in the Assumptions of the Writing Panel section in the "Major Recommendations" field.
Voting Panel Modifications to Writing Panel Materials
At the start of the in-person voting panel meeting, the voting panel was reminded that they have the ability to amend the original writing panel materials if the amendments resulted in more clinically relevant and practical criteria. In order to amend the original materials, the voting panel members were instructed that a member must make a motion to amend and another member must "second" that motion, after which a vote is conducted. If a majority of voting panel members voted "yes" to amend the original materials, the amendments were accepted. See the "Methods" section in the original guideline document for amendments/additions to the original AUC materials.
A multidisciplinary panel of clinicians was assembled to determine the appropriateness of treatments for anterior cruciate ligament injuries. Two non-voting moderators, who are orthopaedic surgeons but are not specialists in the treatment of anterior cruciate ligament injuries, moderated the voting panel. The moderators were familiar with the methods and procedures of AAOS Appropriate Use Criteria and led the panel (as non-voters) in discussions. Additionally, no member of the voting panel was involved in the development (writing panel) or independent review (review panel) of the scenarios.
The voting panel used a modified Delphi procedure to determine appropriateness ratings. The voting panel participated in two rounds of voting while considering evidence-based information provided in the literature review. While cost is often a relevant consideration, panelists focused their appropriateness ratings on the effectiveness of treatment for anterior cruciate ligament injuries.
When rating the appropriateness of a scenario, the voting panel considered the following definition:
"An appropriate treatment for anterior cruciate ligament injuries is one for which the treatment is generally acceptable, is a reasonable approach for the indication, and is likely to improve the patient's health outcomes or survival."
They then rated each scenario using their best clinical judgment, taking into consideration the available evidence, for an average patient presenting to an average physician at an average facility as follows:
Table. Interpreting the 9-Point Appropriateness Scale
Appropriate for the indication provided, meaning treatment is generally acceptable and is a reasonable approach for the indication and is likely to improve the patient's health outcomes or survival.
|4-6||May Be Appropriate:
Uncertain for the indication provided, meaning treatment may be acceptable and may be a reasonable approach for the indication, but with uncertainty implying that more research and/or patient information is needed to further classify the indication.
Rarely an appropriate option for management of patients in this population due to the lack of a clear benefit/risk advantage; rarely an effective option for individual care plans; exceptions should have documentation of the clinical reasons for proceeding with this care option (i.e., procedure is not generally acceptable and is not generally reasonable for the indication).
Each panelist uses the scale below to record their response for each scenario:
Appropriateness of [Topic]
- Rarely Appropriate: 1, 2, 3
- May Be Appropriate: 4, 5, 6
- Appropriate: 7, 8, 9
Round One Voting
The first round of voting occurred after completion of the independent review of the scenarios by the review panel and approval of the final indications, scenarios, and assumptions by the writing panel. The voting panel rated the scenarios electronically using a personalized ballot created by AAOS staff using the AAOS AUC Electronic Ballot Tool. There was no interaction between panel members while completing the first round of voting. Panelists considered the following materials:
- The instructions for rating appropriateness
- The completed literature review, that is appropriately referenced when evidence is available for a scenario
- The list of indications, definitions, and assumptions, to ensure consistency in the interpretation of the clinical scenarios
Round Two Voting
The second round of voting occurred during the in-person voting panel meeting on April 25, 2015. Before the in-person meeting started, each panelist received a personalized document that included their first-round ratings along with summarized results of the first-round ratings that resulted in disagreement. These results indicated the frequency of ratings for a scenario for all panelists. The document contained no identifying information for other panelists' ratings. The moderator also used a document that summarized the results of the panelists' first-round voting. These personalized documents served as the basis for discussions of scenarios which resulted in disagreement.
During the discussion, the voting panel members were allowed to record a new rating for any scenarios if they were persuaded to do so by the discussion or the evidence. After the final ratings were submitted, AAOS staff used the AAOS AUC Electronic Ballot Tool to export the median values and level of agreement for all voting items. There was no attempt to obtain consensus among the panel members.
Using the median value of the second-round ratings, AAOS staff determined the final levels of appropriateness. Disagreement among raters can affect the final rating. Agreement and disagreement were determined using the BIOMED definitions of Agreement and Disagreement, as reported in the RAND/UCLA Appropriate Method User's Manual, for a panel of 8-10 voting members (see Table 2 in the original guideline document). For this panel size, disagreement is defined as when ≥3 members' appropriateness ratings fell within the appropriate (7-9) and rarely appropriate (1-3) ranges for any scenario (i.e., ≥3 members' ratings fell between 1-3 and ≥5 members' ratings fell between 7-9 on any given scenario and its treatment). If there is still disagreement in the voting panel ratings after the second round of voting, that voting item is labeled as "5" regardless of median score. Agreement is defined as ≤2 panelists rated outside of the 3-point range containing the median.
See Table 3 in the original guideline document for more information on final ratings.
A formal cost analysis was not performed and published cost analyses were not reviewed.
Internal Peer Review
American Academy of Orthopaedic Surgeons (AAOS) Appropriate Use Criteria (AUC) Section, the AAOS Council on Research and Quality, and the AAOS Board of Directors sequentially approved the Appropriate Use Criteria for Management of Anterior Cruciate Ligament Injuries. See Appendix A in the original guideline document for additional information on documentation of approval.
The type of evidence supporting the recommendations is not specifically stated.
This Appropriate Use Criteria (AUC) for the treatment of anterior cruciate ligament injuries is based on a review of the available literature regarding treatment of anterior cruciate ligament injuries and a list of clinical scenarios (i.e., criteria) constructed and voted on by experts in orthopaedic surgery and other relevant medical fields.
The appropriate use criteria for treatment of anterior cruciate ligament injuries are expected to improve patient care and obtain the best outcomes for patients.
Most treatments are associated with some known risks, especially invasive and operative treatments. A particular concern when treating anterior cruciate ligament (ACL) injuries is routine surgical complications such as infection, deep vein thrombosis (DVT), anesthesia complications, etc. Other complications associated with ACL surgery include: postoperative loss of motion or arthrofibrosis, ongoing instability episodes, neurovascular injury, etc. Additional factors may affect the physician's choice of treatment including but not limited to associated injuries the patient may present with as well as the individual's co-morbidities, skeletal maturity, and/or specific patient characteristics including obesity, activities, work demands, etc.
Contraindications vary widely based on the treatment administered.
- Volunteer physicians from multiple medical specialties created and categorized these Appropriate Use Criteria. These Appropriate Use Criteria are not intended to be comprehensive or a fixed protocol, as some patients may require more or less treatment or different means of diagnosis. These Appropriate Use Criteria represent patients and situations that clinicians treating or diagnosing musculoskeletal conditions are most likely to encounter. The clinician's independent medical judgment, given the individual patient's clinical circumstances, should always determine patient care and treatment.
- These criteria should not be construed as including all indications or excluding indications reasonably directed to obtaining the same results. The criteria intend to address the most common clinical scenarios facing all appropriately trained surgeons and all qualified physicians managing patients under consideration for treating anterior cruciate ligament injuries. The ultimate judgment regarding any specific criteria should address all circumstances presented by the patient and the needs and resources particular to the locality or institution. It is also important to state that these criteria were developed as guidelines and are not meant to supersede clinician expertise and experience or patient preference.
- Some drugs or medical devices referenced or described in this document may not have been cleared by the Food and Drug Administration (FDA) or may have been cleared for a specific use only. The FDA has stated that it is the responsibility of the physician to determine the FDA clearance status of each drug or device he or she wishes to use in clinical practice.
Disseminating Appropriate Use Criteria
All American Academy of Orthopaedic Surgeons (AAOS) Appropriate Use Criteria (AUCs) can be accessed via a user-friendly app that is available via the OrthoGuidelines Web site (www.orthoguidelines.org ) or as a native app via the Apple and Google Play stores.
Publication of the Appropriate Use Criteria (AUC) document is on the American Academy of Orthopaedic Surgeons (AAOS) Web site at http://www.aaos.org/auc . This document provides interested readers with full documentation about the development of Appropriate Use Criteria and further details of the criteria ratings.
AUCs are first announced by an Academy press release and then published on the AAOS Web site. AUC summaries are published in the AAOS Now and the Journal of the American Academy of Orthopaedic Surgeons (JAAOS). In addition, the Academy's Annual Meeting showcases the AUCs on Academy Row and at Scientific Exhibits.
The dissemination efforts of AUC include Web-based mobile applications, webinars, and online modules for the Orthopaedic Knowledge Online website, radio media tours, and media briefings. In addition AUCs are also promoted in relevant Continuing Medical Education (CME) courses and distributed at the AAOS Resource Center.
Other dissemination efforts outside of the AAOS include submitting AUCs to the National Guideline Clearinghouse and to other medical specialty societies' meetings.
Mobile Device Resources
|American Academy of Orthopaedic Surgeons (AAOS). American Academy of Orthopaedic Surgeons appropriate use criteria for the treatment of anterior cruciate ligament injuries. Rosemont (IL): American Academy of Orthopaedic Surgeons (AAOS); 2015 Oct 2. 35 p. [3 references]|
Not applicable: The guideline was not adapted from another source.
2015 Oct 2
American Academy of Orthopaedic Surgeons - Medical Specialty Society
The American Academy of Orthopaedic Surgeons exclusively funded development of these Appropriate Use Criteria. The American Academy of Orthopaedic Surgeons received no funding from outside commercial sources to support the development of these Appropriate Use Criteria.
Appropriate Use Criteria for Treatment of Anterior Cruciate Ligament Injuries Writing Panel
Writing Panel Members: Robert Marx, MD, MSc, FRCSC, American Orthopaedic Society for Sports Medicine; Rick Wright, MD, American Orthopaedic Society for Sports Medicine; Jeffrey P. Feden, MD, FACEP, American College of Emergency Physicians; Brian Pietrosimone PhD, ATC, National Academy of Sports Medicine; Anthony Beutler, MD, American Medical Society for Sports Medicine; Daniel C. Herman, MD, PhD, CAQSM, American Academy of Physical Medicine and Rehabilitation; Christopher C. Kaeding MD, International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine; Robert A. Magnussen MD, MPH, International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine; David Anthony Parker MBBS, BMedSci, FRACS, International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine; Elvire Servien MD, PhD, Prof, International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine; Peter H. Seidenberg, MD, FAAFP, FACSM, American College of Sports Medicine; Michael Khazzam, MD, American Academy of Orthopaedic Tonsure; William G. DeLong Jr., MD, American College of Surgeons
Voting Panel Members: Sandra J. Shultz, PhD, National Athletic Trainers' Association; Kevin R. Vincent, MD, PhD, American Academy of Physical Medicine and Rehabilitation; T. David Hayes, MD, The Knee Society; Douglas W. Lundy, MD, American College of Surgeons; Moira Davenport, MD, American College of Emergency Physicians; Anna L. Waterbrook, MD, FACEP, American College of Emergency Physicians; Bradley J. Nelson, MD, American Orthopaedic Society for Sports Medicine; Steven B. Singleton, MD, Arthroscopy Association of North America; Neeru Jayanthi, MD, American Medical Society for Sports Medicine; Cynthia R. LaBella, MD, American Medical Society for Sports Medicine
Voting Panel Round Two Discussion Moderators: James O. Sanders, MD; Gregory A. Brown, MD, PhD
Appropriate Use Criteria (AUC) Section Leader, American Academy of Orthopaedic Surgeons (AAOS) Committee on Evidence-Based Quality and Value: Robert H. Quinn, MD
Chair, AAOS Committee on Evidence-Based Quality and Value: David S. Jevsevar, MD, MBA
Chair, AAOS Council on Research and Quality: Kevin J. Bozic, MD, MBA
AAOS Staff: William O. Shaffer, MD, Medical Director; Deborah S. Cummins, PhD, Director, Department of Research and Scientific Affairs; Jayson Murray, MA, Manager, Evidence-Based Medicine Unit; Ryan Pezold, MA, Research Analyst, Evidence-Based Medicine Unit; Peter Shores, MPH, Statistician, Evidence-Based Medicine; Kaitlyn Sevarino, Evidence-Based Quality and Value (EBQV) Coordinator; Erica Linskey, Administrative Assistant, Evidence-Based Medicine Unit
In accordance with American Academy of Orthopaedic Surgeons policy, all individuals whose names appear as authors or contributors to this document filed a disclosure statement as part of the submission process. All authors provided full disclosure of potential conflicts of interest prior to participation in the development of these Appropriate Use Criteria. Disclosure information for all panel members can be found in Appendix B of the original guideline document.
This is the current release of the guideline.
This guideline meets NGC's 2013 (revised) inclusion criteria.
Available from the American Academy of Orthopaedic Surgeons (AAOS) Web site and the OrthoGuidelines Web site .
The following are available:
- American Academy of Orthopaedic Surgeons (AAOS). American Academy of Orthopaedic Surgeons clinical practice guideline on management of anterior cruciate ligament injuries. Rosemont (IL): American Academy of Orthopaedic Surgeons (AAOS); 2014 Sep 5. 619 p. Available from the American Academy of Orthopaedic Surgeons (AAOS) Web site .
- ACL reconstruction surgery: patient postoperative rehabilitation checklist. Rosemont (IL): American Academy of Orthopaedic Surgeons (AAOS). 1 p. Available from the AAOS Web site .
- ACL reconstruction surgery: patient return to play checklist. Rosemont (IL): American Academy of Orthopaedic Surgeons (AAOS). 1 p. Available from the AAOS Web site .
- AUC process. Rosemont (IL): American Academy of Orthopaedic Surgeons (AAOS). 9 p. Available from the AAOS Web site .
A mobile app for the appropriate use criteria for the treatment of anterior cruciate ligament injuries is available on the AAOS Web site .
This NGC summary was completed by ECRI Institute on November 29, 2016. The information was verified by the guideline developer on December 22, 2016. This summary was updated by ECRI Institute on February 15, 2017 following the U.S. Food and Drug Administration advisory on general anesthetic and sedation drugs.
This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. For more information, please contact AAOS Department of Research and Scientific Affairs, 9400 West Higgins Road, Rosemont, IL 60018; Phone: (847) 823-7186; Fax: (847) 823-8125.
The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.
All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities.
Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria.
NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.
Readers with questions regarding guideline content are directed to contact the guideline developer.