The GIN-McMaster guideline tool extension for the integration of quality improvement and quality assurance in guidelines: a description of the methods for its development

British Society of Gastroenterology guidelines on colorectal surveillance in inflammatory bowel disease

Patients with inflammatory bowel disease (IBD) remain at increased risk for colorectal cancer and death from colorectal cancer compared with the general population despite improvements in inflammation control with advanced therapies, colonoscopic surveillance and reductions in environmental risk factors. This guideline update from 2010 for colorectal surveillance of patients over 16 years with colonic inflammatory bowel disease was developed by stakeholders representing UK physicians, endoscopists, surgeons, specialist nurses and patients with GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodological support.An a priori protocol was published describing the approach to three levels of statement: GRADE recommendations, good practice statements or expert opinion statements. A systematic review of 7599 publications, with appraisal and GRADE analysis of trials and network meta-analysis, where appropriate, was performed. Risk thresholding guided GRADE judgements.We made 73 statements for the delivery of an IBD colorectal surveillance service, including outcome standards for service and endoscopist audit, and the importance of shared decision-making with patients.Core areas include: risk of colorectal cancer, IBD-related post-colonoscopy colorectal cancer; service organisation and supporting patient concordance; starting and stopping surveillance, who should or should not receive surveillance; risk stratification, including web-based multivariate risk calculation of surveillance intervals; colonoscopic modalities, bowel preparation, biomarkers and artificial intelligence aided detection; chemoprevention; the role of non-conventional dysplasia, serrated lesions and non-targeted biopsies; management of dysplasia, both endoscopic and surgical, and the structure and role of the multidisciplinary team in IBD dysplasia management; training in IBD colonoscopic surveillance, sustainability (green endoscopy), cost-effectiveness and patient experience. Sixteen research priorities are suggested.

Enhancing health equity considerations in guidelines: health equity extension of the GIN-McMaster Guideline Development Checklist

Background

Practice guidelines may reduce health inequities by addressing preventable and unjust differences in health. However, health equity considerations are often inadequately integrated into the guideline planning and development process. This article describes a pragmatic approach to enhancing health equity considerations within guidelines by introducing an extension to the GIN-McMaster Guideline Development Checklist (GDC).

Methods

We reviewed the latest guidance on enhancing health equity considerations in guideline development to draft the checklist and deployed a global online survey from March 27th, 2024, to May 13th, 2024 to gather consensus. We conducted a methodological review of guideline development handbooks to identify best practices in health equity considerations. An advisory board comprised of diverse interest-holders informed the development of the checklist. We made revisions based on the survey feedback and review findings.

Findings

We present 21 extension items spanning 16 of the 18 guideline development topics from the GIN-McMaster GDC. Key additions include planning for engagement with individuals experiencing inequities in guideline development activities, applying an equity lens, and considering health equity in recommendation formulation, dissemination and implementation strategies. This checklist gives value to lived experiences to enrich health equity assessments, complementing empirical evidence to inform guideline recommendations. Guideline developers should assess guideline sensitivity to health equity to determine resource prioritization for optimal implementation of the extension items.

Interpretation

The GIN-McMaster health equity extension provides guidance for the streamlined integration of health equity considerations throughout the guideline development process. Using this tool alongside the original GIN-McMaster GDC may lead to more equitable and impactful guidelines.

Funding

This project was partially funded by Public Health Agency of Canada. The funder was not involved in the conceptualization or design or the conduct of the project.

Update from 2010 (standard operating procedure): protocol for the 2024 British Society of Gastroenterology Guidelines on colorectal surveillance in inflammatory bowel disease

INTRODUCTION

The evolving landscape of inflammatory bowel disease (IBD) necessitates refining colonoscopic surveillance guidelines. This study outlines methodology adopted by the British Society of Gastroenterology (BSG) Guideline Development Group (GDG) for updating IBD colorectal surveillance guidelines.

METHODS AND ANALYSIS

The 'Grading of Recommendations, Assessment, Development and Evaluation' (GRADE) approach, as outlined in the GRADE handbook, was employed. Thematic questions were formulated using either the 'patient, intervention, comparison and outcome' format or the 'current state of knowledge, area of interest, potential impact and suggestions from experts in the field' format. The evidence review process included systematic reviews assessed using appropriate appraisal tools. An extensive list of potential outcomes was compiled from literature and expert consultations and then ranked by GDG members. The top outcomes were identified for evidence synthesis in three key areas: utility of surveillance in IBD, quality of bowel preparation and use of advanced imaging techniques in colonoscopy for IBD. Risk thresholding exercises determined specific risk levels for different surveillance strategies and intervals. This approach enabled the GDG to establish precise thresholds for interventions based on relative and absolute risk assessments, directly informing the stratification of surveillance recommendations. Significance of effect sizes (small, moderate, large) will guide the final GRADE assessment of the evidence.

ETHICS AND DISSEMINATION

Ethics approval is not applicable. By integrating clinical expertise, patient experiences and innovative methodologies like risk thresholding, we aim to deliver actionable recommendations for IBD colorectal surveillance. This protocol, complementing the main guidelines, offers GDGs, clinical trialists and practitioners a framework to inform future research and enhance patient care and outcomes.

What can nurses learn from patient's needs and wishes when developing an evidence-based quality improvement learning culture? A qualitative study

BACKGROUND

Patient participation is fundamental in nursing care and has yielded benefits for patient outcomes. However, despite their compassionate care approach, nurses do not always incorporate patients' needs and wish into evidence-based practice, quality improvement or learning activities. Therefore, a shift to continuous quality improvement based on evidence-based practice is necessary to enhance the quality of care. The patient's opinion is an essential part of this process. To establish a more sustainable learning culture for evidence-based quality improvement, it is crucial that nurses learn alongside their patients. However, to promote this, nurses require a deeper understanding of patients' care preferences.

OBJECTIVE

To explore patients' needs and wishes towards being involved in care processes that nurses can use in developing an evidence-based quality improvement learning culture.

METHODS

A qualitative study was conducted in two hospital departments and one community care team. In total, 18 patients were purposefully selected for individual semi-structured interviews with an average of 15 min. A framework analysis based on the fundamental of care framework was utilised to analyse the data deductively. In addition, inductive codes were added to patients' experiences beyond the framework. For reporting this study, the SRQR guideline was used.

RESULTS

Participants needed a compassionate nurse who established and sustained a trusting relationship. They wanted nurses to be present and actively involved during the care delivery. Shared decision-making improved when nurses offered fair, clear and tailored information. Mistrust or a disrupted nurse-patient relationship was found to be time-consuming and challenging to restore.

CONCLUSIONS

Results confirmed the importance of a durable nurse-patient relationship and showed the consequences of nurses' communication on shared decision-making. Insights into patients' care preferences are essential to stimulate the development of an evidence-based quality improvement learning culture within nursing teams and for successful implementation processes.

GRADE Concept 7: Issues and Insights Linking Guideline Recommendations to Trustworthy Essential Medicine Lists

OBJECTIVES

Guidelines and essential medicine lists (EMLs) bear similarities and differences in the process that lead to decisions. Access to essential medicines is central to achieve universal health coverage. The World Health Organization (WHO) EML has guided prioritization of essential medicines globally for nearly 50 years, and national EMLs (NEMLs) exist in over 130 countries. Guideline and EML decisions, at WHO or national levels, are not always coordinated and aligned. We sought to explore challenges, and potential solutions, for decision-making to support trustworthy medicine selection for EMLs from a Grading of Recommendations, Assessment, Development and Evaluations (GRADE) Working Group perspective. We primarily focus on the WHO EML; however, our findings may be applicable to NEML decisions as well.

STUDY DESIGN AND SETTING

We identified key challenges in connecting the EML to health guidelines by involving a broad group of stakeholders and assessing case studies including real applications to the WHO EML, South Africa NEML, and a multiple sclerosis guideline connected to a WHO EML application for multiple sclerosis treatments. To address challenges, we utilized the results of a survey and feedback from the stakeholders, and iteratively met as a project group. We drafted a conceptual framework of challenges and potential solutions. We presented a summary of the results for feedback to all attendees of the GRADE Working Group meetings in November 2022 (approximately 120 people) and in May 2023 (approximately 100 people) before finalizing the framework.

RESULTS

We prioritized issues and insights/solutions that addressed the connections between the EML and health guidelines. Our suggested solutions include early planning alignment of guideline groups and EMLs, considering shared participation to strengthen linkage, further clarity on price/cost considerations, and using explicit shared criteria to make guideline and EML decisions. We also provide recommendations to strengthen the connection between WHO EML and NEMLs including through contextualization methods.

CONCLUSION

This GRADE concept article, jointly developed by key stakeholders from the guidelines and EMLs field, identified key conceptual issues and potential solutions to support the continued advancement of trustworthy EMLs. Adopting structured decision criteria that can be linked to guideline recommendations bears the potential to advance health equity and gaps in availability of essential medicines within and between countries.