Guidelines should reflect all knowledge, not just clinical trials

Required knowledge for guideline panel members to develop healthcare related testing recommendations: a developmental study

OBJECTIVES

To define the minimum knowledge required for guideline panel members (healthcare professionals and consumers) involved in developing recommendations about healthcare related testing.

STUDY DESIGN AND SETTING

A developmental study with a multistaged approach. We derived a first set of knowledge components from literature and subsequently performed semistructured interviews with 9 experts. We refined the set of knowledge components and checked it with the interviewees for final approval.

RESULTS

Understanding the test-management pathway, for example, how test results should be used in context of decisions about interventions, is the key knowledge component. The final list includes 26 items on the following topics: health question, test-management pathway, target population, test, test result, interpretation of test results and subsequent management, and impact on people important outcomes. For each item, the required level of knowledge is defined.

CONCLUSION

We developed a list of knowledge components required for guideline panels to formulate recommendations on healthcare related testing. The list could be used to design specific training programs for guideline panel members when developing recommendations about tests and testing strategies in healthcare.

Best practice for the selection, design and implementation of UK Kidney Association guidelines: a modified Delphi consensus approach

BACKGROUND

Despite research into how to effectively implement evidence-based recommendations into clinical practice, a lack of standardisation in the commissioning and development of clinical practice guidelines can lead to inconsistencies and gaps in implementation. This research aimed to ascertain how topics in kidney care worthy of guideline development within the UK should be chosen, prioritised, designed and implemented.

METHODS

Following a modified Delphi methodology, a multi-disciplinary panel of experts in kidney healthcare from across the UK developed 35 statements on the issues surrounding the selection, development and implementation of nephrology guidelines. Consensus with these statements was determined by agreement using an online survey; the consensus threshold was defined as 75% agreement.

RESULTS

419 responses were received. Of the 364 healthcare practitioners (HCPs), the majority had over 20 years of experience in their role (n=123) and most respondents were nephrologists (n=95). Of the 55 non-clinical respondents, the majority were people with kidney disease (n=41) and the rest were their carers or family. Participants were from across England, Northern Ireland, Scotland and Wales. Consensus between HCPs was achieved in 32/35 statements, with 28 statements reaching ≥90% agreement. Consensus between patients and patient representatives was achieved across all 20 statements, with 13/20 reaching ≥90% agreement.

CONCLUSIONS

The current results have provided the basis for six recommendations to improve the selection, design and implementation of guidelines. Actioning these recommendations will help improve the accessibility of, and engagement with, clinical guidelines, contributing to the continuing development of best practice in UK kidney care.

Creating an (ethical) epistemic space for the normalization of clinical and "real food" oral immunotherapy for food allergy

Researchers and sociologists have argued the consequences of standardization vis-à-vis clinical practice guidelines are diverse and argue they should be explored empirically. Sociologists have also argued that "best evidence" for the development of clinical practice guidelines is not restricted to randomized controlled trials and that other forms of knowledge should be embedded in and inform CPGs. There is little research concerning how other types of knowledge are mobilized and taken up in CPGs. This article presents the results of an ethnographic investigation in Canada between 2015 and 2020 of the development of a clinical practice guideline for immunotherapy for food allergy. My research shows that immunotherapy has become the source of controversy regarding whether immunotherapy should be offered in the clinic or remain experimental and whether it should be offered using food or commercial products. I argue that the clinical practice guideline for oral immunotherapy reaffirms what has been previously noted by sociologists; guidelines can serve normative purposes and are not merely technical documents. This case study is unique as it demonstrates how guidelines can serve as "community-making devices" to consolidate "epistemic communities" through the explicit and formal mobilization of ethical principles alongside other forms of "traditional" evidence. The mobilization of a multi-criteria approach that included ethical principles was mobilized in part to counter the de-legitimization and peripheralization of clinical and real food oral immunotherapy.

Improvement, Implementation, and Evaluation of the CMyLife Digital Care Platform: Participatory Action Research Approach

BACKGROUND

The evaluation of a continuously evolving eHealth tool in terms of improvement and implementation in daily practice is unclear. The CMyLife digital care platform provides patient-centered care by empowering patients with chronic myeloid leukemia, with a focus on making medication compliance insightful, discussable, and optimal, and achieving optimal control of the biomarker BCR-ABL1.

OBJECTIVE

The aim of this study was to investigate to what extent the participatory action research approach is suitable for the improvement and scientific evaluation of eHealth innovations in daily clinical practice (measured by user experiences) combined with the promotion of patient empowerment.

METHODS

The study used iterative cycles of planning, action, and reflection, whereby participants' experiences (patients, health care providers, the CMyLife team, and app suppliers) with the platform determined next actions. Co-design workshops were the foundation of this cyclic process. Moreover, patients filled in 2 sets of questionnaires for assessing experiences with CMyLife, the actual use of the platform, and the influence of the platform after 3 and at least 6 months. Data collected during the workshops were analyzed using content analysis, which is often used for making a practical guide to action. Descriptive statistics were used to characterize the study population in terms of information related to chronic myeloid leukemia and sociodemographics, and to describe experiences with the CMyLife digital care platform and the actual use of this platform.

RESULTS

The co-design workshops provided insights that contributed to the improvement, implementation, and evaluation of CMyLife and empowered patients with chronic myeloid leukemia (for example, simplification of language, and improvement of the user friendliness of functionalities). The results of the questionnaires indicated that (1) the platform improved information provision on chronic myeloid leukemia in 67% (33/49) of patients, (2) the use of the medication app improved medication compliance in 42% (16/38) of patients, (3) the use of the guideline app improved guideline adherence in 44% (11/25) of patients, and (4) the use of the platform caused patients to feel more empowered.

CONCLUSIONS

A participatory action research approach is suited to scientifically evaluate digital care platforms in daily clinical practice in terms of improvement, implementation, and patient empowerment. Systematic iterative evaluation of users' needs and wishes is needed to keep care centered on patients and keep the innovation up-to-date and valuable for users.

Capturing Emerging Experiential Knowledge for Vaccination Guidelines Through Natural Language Processing: Proof-of-Concept Study

BACKGROUND

Experience-based knowledge and value considerations of health professionals, citizens, and patients are essential to formulate public health and clinical guidelines that are relevant and applicable to medical practice. Conventional methods for incorporating such knowledge into guideline development often involve a limited number of representatives and are considered to be time-consuming. Including experiential knowledge can be crucial during rapid guidance production in response to a pandemic but it is difficult to accomplish.

OBJECTIVE

This proof-of-concept study explored the potential of artificial intelligence (AI)-based methods to capture experiential knowledge and value considerations from existing data channels to make these insights available for public health guideline development.

METHODS

We developed and examined AI-based methods in relation to the COVID-19 vaccination guideline development in the Netherlands. We analyzed Dutch messages shared between December 2020 and June 2021 on social media and on 2 databases from the Dutch National Institute for Public Health and the Environment (RIVM), where experiences and questions regarding COVID-19 vaccination are reported. First, natural language processing (NLP) filtering techniques and an initial supervised machine learning model were developed to identify this type of knowledge in a large data set. Subsequently, structural topic modeling was performed to discern thematic patterns related to experiences with COVID-19 vaccination.

RESULTS

NLP methods proved to be able to identify and analyze experience-based knowledge and value considerations in large data sets. They provide insights into a variety of experiential knowledge that is difficult to obtain otherwise for rapid guideline development. Some topics addressed by citizens, patients, and professionals can serve as direct feedback to recommendations in the guideline. For example, a topic pointed out that although travel was not considered as a reason warranting prioritization for vaccination in the national vaccination campaign, there was a considerable need for vaccines for indispensable travel, such as cross-border informal caregiving, work or study, or accessing specialized care abroad. Another example is the ambiguity regarding the definition of medical risk groups prioritized for vaccination, with many citizens not meeting the formal priority criteria while being equally at risk. Such experiential knowledge may help the early identification of problems with the guideline's application and point to frequently occurring exceptions that might initiate a revision of the guideline text.

CONCLUSIONS

This proof-of-concept study presents NLP methods as viable tools to access and use experience-based knowledge and value considerations, possibly contributing to robust, equitable, and applicable guidelines. They offer a way for guideline developers to gain insights into health professionals, citizens, and patients' experience-based knowledge, especially when conventional methods are difficult to implement. AI-based methods can thus broaden the evidence and knowledge base available for rapid guideline development and may therefore be considered as an important addition to the toolbox of pandemic preparedness.

Passive tolerance and productive uncertainties in food allergy immunotherapy biomedical practices

There has been little sociological research on food allergy in North America, despite the fact that it impacts a significant population in the US and Canada. Immunotherapy for food allergy is now a prominent area of investigation and experts argue it is one dimension of a 'paradigm shift' that encourages exposure to food allergens in contrast to avoidance of them. This article reports on an ethnographic investigation of immunotherapy for food allergy research and practice between the years 2015 and 2020. I report on analyses of N = 31 in-depth interviews with spokespersons with different types of engagement in immunotherapy and over 100 h of ethnographic observations at clinical and scientific conferences. My research revealed the entangled ontologies of food and drug in immunotherapy and related uncertainties in the diagnoses of food allergy, which catalysed further uncertainty about who is receiving and who should receive immunotherapy (IT). Relatedly, there are uncertainties about the goals and/or outcomes of IT. I elaborate on previous sociological work about how uncertainty is valued in medicine and science. I argue shared uncertainties and mutual scepticism in IT co-exist, representing a passive (productive) tolerance and reticently accepted form of tension in the domain, which have resulted in calls for intra-professional and inter-professional collaborations and the involvement of other stakeholders in knowledge making regarding food allergy immunotherapy.

Characterisation of hospital-produced guidelines regarding management of temporary tube feeding care in general paediatric patients

Background/Aims

There is significant variation in the implementation of temporary tube feeding management in children and a paucity of associated clinical practice guidelines covering all phases of care, from decision making regarding tube insertion through to tube weaning. Development of clinical practice guidelines should consider levels of evidence other than randomised control trials. Examining hospital-produced guidelines used by frontline health staff, for example, could distinguish areas of application of evidence-based recommendations, as well as domains of care in need of increased implementation. This article describes the content of existing hospital-produced guidelines relating to tube feeding care in a general paediatric population.

Methods

Hospital-produced guidelines were sought by mailing 200 health services worldwide and searching Queensland Health's Electronic Publishing Service in Australia and Google. A content analysis was then performed.

Results

The 13 collected hospital-produced guidelines from Australia, the UK and Canada generally comprehensively reported on processes related to the decision-making, tube placement and tube maintenance phases. However, reporting on oral feeding while tube feeding, tube feeding dependency, tube feeding exit planning, and the social and emotional aspects of tube feeding were areas within these phases that had limited coverage. Recommendations for the phase of tube weaning were also infrequently included.

Conclusions

Development of formal clinical practice guidelines covering all tube feeding phases should assist in optimising patient and health service outcomes.

Routinely collected patient data in neurology research: a systematic mapping review

BACKGROUND

This review focuses on neurology research which uses routinely collected data. The number of such studies is growing alongside the expansion of data collection. We aim to gain a broad picture of the scope of how routine healthcare data have been utilised.

METHODS

This study follows a systematic mapping review approach which does not make a judgement on the quality of the papers included in the review, thereby enabling a complete overview of the field.

RESULTS

Of 4481 publications retrieved, 386 met the eligibility criteria for this study. These publications covered a wide range of conditions, but the majority were based on one or only a small number of neurological conditions. In particular, publications concerned with three discrete areas of neurological practice - multiple sclerosis (MS), epilepsy/seizure and Parkinson's disease - accounted for 60% of the total. MS was the focus of the highest proportion of eligible studies (35%), yet in the recent Global Burden of Neurological Disease study it ranks only 14th out of 15 neurological disorders for DALY rates. In contrast, migraine is the neurological disorder with the highest ranking of DALYs globally (after stroke) and yet it was represented by only 4% of eligible studies.

CONCLUSION

This review shows that there is a disproportionately large body of literature pertaining to relatively rare disorders, and a correspondingly small body of literature describing more common conditions. Therefore, there is potential for future research to redress this balance.

Navigating complexity of child abuse through intuition and evidence-based guidelines: a mix-methods study among child and youth healthcare practitioners

BACKGROUND

Dutch child and youth health care (CYHC) practitioners monitor and assess the well-being of children. One of their main concerns is identifying cases of child abuse, which is an arduous and sensitive task. In these contexts, CYHC-practitioners use both evidence-based guidelines aimed at increasing the quality of care through rationalised decision-making, and intuition. These two practices are seen as being at odds with each other, yet empirical research has shown that both are necessary in healthcare. This study aims to unravel how intuition is perceived and used by Dutch CYHC-practitioners when identifying and working with cases of child abuse, and how this relates to their evidence-based guidelines.

METHODS

A sequential exploratory mixed-methods design: in-depth semi-structured interviews with CYHC-physicians focused on perceptions on intuition, which were followed by a survey amongst CYHC-practitioners on the recognition and use of the concept.

RESULTS

The majority of CYHC-practitioners recognise and use intuition in their daily work, stating that it is necessary in their profession. CYHC-practitioners use intuition to 1) sense that something is 'off', 2) differentiate between 'normal' and 'abnormal', 3) assess risks, 4) weigh secondary information and 5) communicate with parents. At the same time, they warn of its dangers, as it may lead to 'tunnel vision' and false accusations.

CONCLUSION

Intuition is experienced as an integral part of the work of CYHC-practitioners. It is understood as particularly useful in cases of child abuse, which are inherently complex, as signs and evidence of abuse are often hidden, subtle and unique in each case. CYHC-practitioners use intuition to manage and navigate this complexity. There is an opportunity for guidelines to support reflection and intuition as a 'good care' practice.

How do guideline developers identify, incorporate and report patient preferences? An international cross-sectional survey

Background

Guidelines based on patient preferences differ from those developed solely by clinicians and may promote patient adherence to guideline recommendations. There is scant evidence on how to develop patient-informed guidelines. This study aimed to describe how guideline developers identify, incorporate and report patient preferences.

Methods

We employed a descriptive cross-sectional survey design. Eligible organizations were non-profit agencies who developed at least one guideline in the past five years and had considered patient preferences in guideline development. We identified developers through the Guidelines International Network and publicly-available guideline repositories, administered the survey online, and used summary statistics to report results.

Results

The response rate was 18.3% (52/284). Respondents included professional societies, and government, academic, charitable and healthcare delivery organizations from 18 countries with at least 1 to ≥6 years of experience generating patient-informed guidelines. Organizations most frequently identified preferences through patient panelists (86.5%) and published research (84.6%). Most organizations (48, 92.3%) used multiple approaches to identify preferences (median 3, range 1 to 5). Most often, organizations used preferences to generate recommendations (82.7%) or establish guideline questions (73.1%). Few organizations explicitly reported preferences; instead, they implicitly embedded preferences in guideline recommendations (82.7%), questions (73.1%), or point-of-care communication tools (61.5%). Most developers had little capacity to generate patient-informed guidelines. Few offered training to patients (30.8%), or had dedicated funding (28.9%), managers (9.6%) or staff (9.6%). Respondents identified numerous barriers to identifying preferences. They also identified processes, resources and clinician- and patient-strategies that can facilitate the development of patient-informed guidelines. In contrast to identifying preferences, developers noted few approaches for, or barriers or facilitators of incorporating or reporting preferences.

Conclusions

Developers emphasized the need for knowledge on how to identify, incorporate and report patient preferences in guidelines. In particular, how to use patient preferences to formulate recommendations, and transparently report patient preferences and the influence of preferences on guidelines is unknown. Still, insights from responding developers may help others who may be struggling to generate guidelines informed by patient preferences.

A conceptual framework for patient-directed knowledge tools to support patient-centred care: Results from an evidence-informed consensus meeting

OBJECTIVE

Patient-directed knowledge tools are designed to engage patients in dialogue or deliberation, to support patient decision-making or self-care of chronic conditions. However, an abundance of these exists. The tools themselves and their purposes are not always clearly defined; creating challenges for developers and users (professionals, patients). The study's aim was to develop a conceptual framework of patient-directed knowledge tool types.

METHODS

A face-to-face evidence-informed consensus meeting with 15 international experts. After the meeting, the framework went through two rounds of feedback before informal consensus was reached.

RESULTS

A conceptual framework containing five patient-directed knowledge tool types was developed. The first part of the framework describes the tools' purposes and the second focuses on the tools' core elements.

CONCLUSION

The framework provides clarity on which types of patient-directed tools exist, the purposes they serve, and which core elements they prototypically include. It is a working framework and will require further refinement as the area develops, alongside validation with a broader group of stakeholders.

PRACTICE IMPLICATIONS

The framework assists developers and users to know which type a tool belongs, its purpose and core elements, helping them to develop and use the right tool for the right job.

Lipid management for coronary heart disease patients: an appraisal of updated international guidelines applying Appraisal of Guidelines for Research and Evaluation II-clinical practice guideline appraisal for lipid management in coronary heart disease

BACKGROUND

Clinical practice guidelines (CPGs) provide many recommendations for hyperlipidemia management, but some of them are still debatable.

METHODS

We applied the six-domain Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument to evaluate the quality of guidelines with lipid management recommendations for coronary heart disease (CHD), including dyslipidemia and CHD guidelines published from 2009 to 2019. Meanwhile, we synthesized and compared major recommendations and present the consistency and controversy in current dyslipidemia management.

RESULTS

Among 19 guidelines included, ten guidelines ("strongly recommended" with AGREE scores 61-94%) performed better than the other nine (38-65% as "recommended with some modification") For blood lipid tests, most CHD guidelines simply required fasting sample while dyslipidemia guidelines preferred non-fasting sample except in high triglycerides state. Most guidelines consistently chose low-density lipoprotein cholesterol (LDL-C) as the primary lipid-lowering target (LLT), while non-high-density lipoprotein cholesterol (non-HDL-C) and apolipoprotein B were mainly selected as secondary LLTs. The specific goals of LDL-C lowering were either to lower than 70 mg/dL or with at least 50% reduction. All guidelines recommended high intensity or maximally tolerable doses of statins, while ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors were recommended as second-line therapy.

CONCLUSIONS

The general quality of guidelines for lipid management is satisfactory. Consensus has been reached on the specific goal of lipid reduction and the intensity of statins therapy. Further research is needed to validate the application of non-fasting sample and non-HDL-C target, as well as the efficacy and safety of ezetimibe and PCSK9 inhibitors.

How Knowledge Is Constructed and Exchanged in Virtual Communities of Physicians: Qualitative Study of Mindlines Online

BACKGROUND

As a response to the criticisms evidence-based practice currently faces, groups of health care researchers and guideline makers have started to call for the appraisal and inclusion of different kinds of knowledge in guideline production (other than randomized controlled trials [RCTs]) to better link with the informal knowledge used in clinical practice. In an ethnographic study, Gabbay and Le May showed that clinicians in everyday practice situations do not explicitly or consciously use guidelines. Instead, they use mindlines: collectively shared, mostly tacit knowledge that is shaped by many sources, including accumulated personal experiences, education (formal and informal), guidance, and the narratives about patients that are shared among colleagues. In this study on informal knowledge, we consider virtual networks of clinicians as representative of the mindlines in the wider medical community, as holders of knowledge, as well as catalysts of knowing.

OBJECTIVE

The aim of this study was to explore how informal knowledge and its creation in communities of clinicians can be characterized as opposed to the more structured knowledge produced in guideline development.

METHODS

This study included a qualitative study of postings on three large virtual networks for physicians in the United Kingdom, the Netherlands, and Norway, taking the topic of statins as a case study and covering more than 1400 posts. Data were analyzed thematically with reference to theories of collaborative knowledge construction and communities of practice.

RESULTS

The dataset showed very few postings referring to, or seeking to adhere to, explicit guidance and recommendations. Participants presented many instances of individual case narratives that highlighted quantitative test results and clinical examination findings. There was an emphasis on outliers and the material, regulatory, and practical constraints on knowledge use by clinicians. Participants conveyed not-so-explicit knowledge as tacit and practical knowledge and used a prevailing style of pragmatic reasoning focusing on what was likely to work in a particular case. Throughout the discussions, a collective conceptualization of statins was generated and reinforced in many contexts through stories, jokes, and imagery.

CONCLUSIONS

Informal knowledge and knowing in clinical communities entail an inherently collective dynamic practice that includes explicit and nonexplicit components. It can be characterized as knowledge-in-context in practice, with a strong focus on casuistry. Validity of knowledge appears not to be based on criteria of consensus, coherence, or correspondence but on a more polyphonic understanding of truth. We contend that our findings give enough ground for further research on how exploring mindlines of clinicians online could help improve guideline development processes.

Improving health promotion through central rating of interventions: the need for Responsive Guidance

BACKGROUND

In several countries, attempts are made to improve health promotion by centrally rating the effectiveness of health promotion interventions. The Dutch Effectiveness Rating System (ERS) for health promotion interventions is an improvement-oriented approach in which multi-disciplinary expert committees rate available health promotion interventions as 'theoretically sound', 'probably effective' or 'proven effective'. The aim of this study is to explore the functioning of the ERS and the perspective of researchers, policy-makers and practitioners regarding its contribution to improvement.

METHODS

We interviewed 53 selected key informants from research, policy and practice in the Netherlands and observed the assessment of 12 interventions.

RESULTS

Between 2008 and 2012, a total of 94 interventions were submitted to the ERS, of which 23 were rejected, 58 were rated as 'theoretically sound', 10 were rated as 'probably effective' and 3 were rated as 'proven effective'. According to participants, the ERS was intended to facilitate both the improvement of available interventions and the improvement of health promotion in practice. While participants expected that describing and rating interventions promoted learning and enhanced the transferability of interventions, they were concerned that the ERS approach was not suitable for guiding intervention development and improving health promotion in practice. The expert committees that assessed the interventions struggled with a lack of norms for the relevance of effects and questions about how effects should be studied and rated. Health promotion practitioners were concerned that the ERS neglected the local adaptation of interventions and did not encourage the improvement of aspects like applicability and costs. Policy-makers and practitioners were worried that the lack of proven effectiveness legitimised cutbacks rather than learning and advancing health promotion.

CONCLUSION

While measuring and centrally rating the effectiveness of interventions can be beneficial, the evidence based-inspired ERS approach is too limited to guide both intervention development and the improvement of health promotion in practice. To better contribute to improving health promotion, a more reflexive and responsive guidance approach is required, namely one which stimulates the improvement of different intervention aspects, provides targeted recommendations to practitioners and provides feedback to those who develop and rate interventions.

Has evidence-based medicine ever been modern? A Latour-inspired understanding of a changing EBM

Evidence-based health care (EBHC), previously evidence-based medicine (EBM), is considered by many to have modernized health care and brought it from an authority-based past to a more rationalist, scientific grounding. But recent concerns and criticisms pose serious challenges and urge us to look at the fundamentals of a changing EBHC. In this paper, we present French philosopher Bruno Latour's vision on modernity as a framework to discuss current changes in the discourse on EBHC/EBM. Drawing on Latour's work, we argue that the early EBM movement had a strong modernist agenda with an aim to "purify" clinical reality into a dichotomy of objective "evidence" from nature and subjective "preferences" from human society and culture. However, we argue that this shift has proved impossible to achieve in reality. Several recent developments appear to point to a demise of purified evidence in the EBHC discourse and a growing recognition-albeit implicit and undertheorized-that evidence in clinical decision making is relentlessly situated and contextual. The unique, individual patient, not abstracted truths from distant research studies, must be the starting point for clinical practice. It follows that the EBHC community needs to reconsider the assumption that science should be abstracted from culture and acknowledge that knowledge from human culture and nature both need translation and interpretation. The implications for clinical reasoning are far reaching. We offer some preliminary principles for conceptualizing EBHC as a "situated practice" rather than as a sequence of research-driven abstract decisions.

A new framing approach in guideline development to manage different sources of knowledge

RATIONALE

Contemporary guideline methodology struggles to consider context and information from different sources of knowledge besides quantitative research. Return to work programmes involve multiple components and stakeholders. If the guideline is to be relevant and practical for a complex intervention such as return to work, it is essential to use broad sources of knowledge.

AIMS AND OBJECTIVE

This paper reports on a new method in guideline development to manage different sources of knowledge.

METHODS

The method used framing for the return-to-work guidance within the Clinical Practice Guidelines for the Management of Rotator Cuff Syndrome in the Workplace. The development involved was a multi-disciplinary working party of experts including consumers. The researchers considered a broad range of research, expert (practice and experience) knowledge, the individual's and workplace contexts, and used framing with the International Classification of Functioning, Disability and Health. Following a systematic database search on four clinical questions, there were seven stages of knowledge management to extract, unpack, map and pack information to the ICF domains framework. Companion graded recommendations were developed.

RESULTS

The results include practical examples, user and consumer guides, flow charts and six graded or consensus recommendations on best practice for return to work intervention.

CONCLUSIONS

Our findings suggest using framing in guideline methodology with internationally accepted frames such as the ICF is a reliable and transparent framework to manage different sources of knowledge. Future research might examine other examples and methods for managing complexity and using different sources of knowledge in guideline development.

The CRISP colorectal cancer risk prediction tool: an exploratory study using simulated consultations in Australian primary care

Background

In Australia, screening for colorectal cancer (CRC) with colonoscopy is meant to be reserved for people at increased risk, however, currently there is a mismatch between individuals’ risk of CRC and the type of CRC screening they receive.

This paper describes the development and optimisation of a Colorectal cancer RISk Prediction tool (‘CRISP’) for use in primary care. The aim of the CRISP tool is to increase risk-appropriate CRC screening.

Methods

CRISP development was informed by previous experience with developing risk tools for use in primary care and a systematic review of the evidence. A CRISP prototype was used in simulated consultations by general practitioners (GPs) with actors as patients. GPs were interviewed to explore their experience of using CRISP, and practice nurses (PNs) and practice managers (PMs) were interviewed after a demonstration of CRISP. Transcribed interviews and video footage of the ‘consultations’ were qualitatively analyzed. Themes arising from the data were mapped onto Normalization Process Theory (NPT).

Results

Fourteen GPs, nine PNs and six PMs were recruited from 12 clinics. Results were described using the four constructs of NPT: 1) Coherence: Clinicians understood the rationale behind CRISP, particularly since they were familiar with using risk tools for other conditions; 2) Cognitive participation: GPs welcomed the opportunity CRISP provided to discuss healthy and unhealthy behaviors with their patients, but many GPs challenged the screening recommendation generated by CRISP; 3) Collective Action: CRISP disrupted clinician-patient flow if the GP was less comfortable with computers. GP consultation time was a major implementation barrier and overall consensus was that PNs have more capacity and time to use CRISP effectively; 4) Reflexive monitoring: Limited systematic monitoring of new interventions is a potential barrier to the sustainable embedding of CRISP.

Conclusions

CRISP has the potential to improve risk-appropriate CRC screening in primary care but was considered more likely to be successfully implemented as a nurse-led intervention.

[Long-term opioid therapy in chronic noncancer pain. A systematic review and meta-analysis of efficacy, tolerability and safety in open-label extension trials with study duration of at least 26 weeks]

BACKGROUND

The efficacy and safety of long-term (≥ 6 months) opioid therapy (LtOT) in chronic noncancer pain (CNCP) is under debate. A systematic review with meta-analysis of the efficacy and harms of opioids in open-label extension studies of randomized controlled trials (RCTs) has not been conducted until now.

METHODS

We screened MEDLINE and clinicaltrials.gov (through to December 2013), as well as reference sections of systematic reviews of long-term RCTs of opioids in CNCP. We included open-label extension trials with a study duration ≥ 26 weeks of RCTs of ≥ 2 weeks duration. Using a random effects model, pooled estimates of event rates for categorical data and standardized mean differences (SMD) for continuous variables were calculated.

RESULTS

We included 11 open-label extension studies with 2445 participants with nociceptive (low back, osteoarthritis) and neuropathic (radicular, polyneuropathy) pain. Median study duration was 26 (range 26-108) weeks. Four studies tested oxycodone, two studies tramadol and buprenorphine; hydromorphone, morphine, oxymorphone and tapentadol were each tested in one study. Of the patients randomized at baseline, 28.5 % (95 % confidence interval, CI, 17.9-39.2 %) finished the open-label period; 53.5 % (95 % CI 38.1-68.2 %) of patients entering the open-label period finished the open-label period. In sum, the total loss was 71.5 % (95 % CI 60.9-83.1 %) of all patients primarily included into the RCT. A total of 4.9 % (95 % CI 2.9-8.2 %) of patients dropped out due lack of efficacy; 16.8 % (95 % CI 11.0-24.8 %) dropped out to due adverse events (AE) in the open-label period and 0.08 % (95 % CI 0.001-0.05 %) of patients died during the open-label period. Only one study systematically assessed aberrant drug behavior of the patients: 5.7 % (95 % CI 3.4-9.6 %) showed aberrant drug behavior in the opinion of the investigators and 2.6 % (95 % CI 1.2-5.8 %) were judged to show aberrant drug behavior by independent expert assessment. There was no significant change (p = 0.50) in pain intensity between the end of the randomized period and the end of open-label phase (SMD 0.19 [- 0.03, 0.41]; six studies with 1360 participants).

CONCLUSION

Only a minority of patients selected for opioid therapy at randomization finished the long-term open-label study. However, sustained effects of pain reduction could be demonstrated in these patients. LtOT can be considered in carefully selected and monitored CNCP patients who experience clinically meaningful pain reduction with at least tolerable AE in short-term opioid therapy. The English full-text version of this article is freely available at SpringerLink (under "Supplementary Material").

Evidence-based policy as reflexive practice. What can we learn from evidence-based medicine?

The call for evidence-based policy is often accompanied by rather uncritical references to the success of evidence-based medicine, leading to often unsuccessful translation attempts. In this paper, I reflect on the practice of evidence-based medicine in an attempt to sketch a more productive approach to translating evidence into the practice of policy making. Discussing three episodes in the history of evidence-based medicine - clinical trials, and the production and use of clinical guidelines - I conclude that the success of evidence-based medicine is based on the creation of reflexive practices in which evidence and practice can be combined productively. In the conclusion, I discuss the prospects of such a practice for evidence-based policy.

Evidence-based medicine: is it a bridge too far?

AIMS

This paper aims to describe the contextual factors that gave rise to evidence-based medicine (EBM), as well as its controversies and limitations in the current health context. Our analysis utilizes two frameworks: (1) a complex adaptive view of health that sees both health and healthcare as non-linear phenomena emerging from their different components; and (2) the unified approach to the philosophy of science that provides a new background for understanding the differences between the phases of discovery, corroboration, and implementation in science.

RESULTS

The need for standardization, the development of clinical epidemiology, concerns about the economic sustainability of health systems and increasing numbers of clinical trials, together with the increase in the computer's ability to handle large amounts of data, have paved the way for the development of the EBM movement. It was quickly adopted on the basis of authoritative knowledge rather than evidence of its own capacity to improve the efficiency and equity of health systems. The main problem with the EBM approach is the restricted and simplistic approach to scientific knowledge, which prioritizes internal validity as the major quality of the studies to be included in clinical guidelines. As a corollary, the preferred method for generating evidence is the explanatory randomized controlled trial. This method can be useful in the phase of discovery but is inadequate in the field of implementation, which needs to incorporate additional information including expert knowledge, patients' values and the context.

CONCLUSION

EBM needs to move forward and perceive health and healthcare as a complex interaction, i.e. an interconnected, non-linear phenomenon that may be better analysed using a variety of complexity science techniques.

Meeting pragmatism halfway: making a pragmatic clinical trial protocol

Pragmatic clinical trials (PCTs) are today an increasingly prominent means of measuring the 'effectiveness' of healthcare interventions in 'real world' clinical settings, in order to produce evidence on which to base regulatory and clinical decision-making. Although several sociological studies have shown persuasively how PCTs are co-constructed within particular healthcare systems in which they are based, they have tended to focus on relatively later stages in careers of trials. The paper contributes to literature by considering how the 'real world' of the UK National Health Service (NHS) is incorporated into the design of a research protocol. Drawing on a meeting held just prior to patient recruitment for a PCT in maternal health, the paper analyses a trial collective's efforts to purify the messy domain of NHS clinical care into the orderly confines of the protocol (Law 2004), which meant satisfying demands for both scientific and social robustness (c.f. Nowotny et al. 2001). The findings show how efforts to inscribe robustness into the PCT protocol were themselves mediated through epistemic and regulatory conventions surrounding protocols as devices in healthcare research. Finally it is argued that meetings constitute an important epistemic instrument through which to settle various emerging tensions in PCT protocol design.

10 years of mindlines: a systematic review and commentary

Background

In 2004, Gabbay and le May showed that clinicians generally base their decisions on mindlines—internalised and collectively reinforced tacit guidelines—rather than consulting written clinical guidelines. We considered how the concept of mindlines has been taken forward since.

Methods

We searched databases from 2004 to 2014 for the term ‘mindline(s)’ and tracked all sources citing Gabbay and le May’s 2004 article. We read and re-read papers to gain familiarity and developed an interpretive analysis and taxonomy by drawing on the principles of meta-narrative systematic review.

Results

In our synthesis of 340 papers, distinguished between authors who used mindlines purely in name (‘nominal’ view) sometimes dismissing them as a harmful phenomenon, and authors who appeared to have understood the term’s philosophical foundations. The latter took an ‘in-practice’ view (studying how mindlines emerge and spread in real-world settings), a ‘theoretical and philosophical’ view (extending theory) or a ‘solution focused’ view (exploring how to promote and support mindline development). We found that it is not just clinicians who develop mindlines: so do patients, in face-to-face and (potentially) online communities.

Theoretical publications on mindlines have continued to challenge the rationalist assumptions of evidence-based medicine (EBM). Conventional EBM assumes a single, knowable reality and seeks to strip away context to generate universal predictive rules. In contrast, mindlines are predicated on a more fluid, embodied and intersubjective view of knowledge; they accommodate context and acknowledge multiple realities. When considering how knowledge spreads, the concept of mindlines requires us to go beyond the constraining notions of ‘dissemination’ and ‘translation’ to study tacit knowledge and the interactive human processes by which such knowledge is created, enacted and shared. Solution-focused publications described mindline-promoting initiatives such as relationship-building, collaborative learning and thought leadership.

Conclusions

The concept of mindlines challenges the naïve rationalist view of knowledge implicit in some EBM publications, but the term appears to have been misunderstood (and prematurely dismissed) by some authors. By further studying mindlines empirically and theoretically, there is potential to expand EBM’s conceptual toolkit to produce richer forms of ‘evidence-based’ knowledge. We outline a suggested research agenda for achieving this goal.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-015-0229-x) contains supplementary material, which is available to authorized users.

Learning from the QUEST multicentre feasibility randomization trials in breast reconstruction after mastectomy

BACKGROUND

Breast reconstruction aims to improve health-related quality of life after mastectomy. However, evidence guiding patients and surgeons in shared decision-making concerning the optimal type or timing of surgery is lacking.

METHODS

QUEST comprised two parallel feasibility phase III randomized multicentre trials to assess the impact of the type and timing of latissimus dorsi breast reconstruction on health-related quality of life when postmastectomy radiotherapy is unlikely (QUEST A) or highly probable (QUEST B). The primary endpoint for the feasibility phase was the proportion of women who accepted randomization, and it would be considered feasible if patient acceptability rates exceeded 25 per cent of women approached. A companion QUEST Perspectives Study (QPS) of patients (both accepting and declining trial participation) and healthcare professionals assessed trial acceptability.

RESULTS

The QUEST trials opened in 15 UK centres. After 18 months of recruitment, 17 patients were randomized to QUEST A and eight to QUEST B, with overall acceptance rates of 19 per cent (17 of 88) and 22 per cent (8 of 36) respectively. The QPS recruited 56 patients and 51 healthcare professionals. Patient preference was the predominant reason for declining trial entry, given by 47 (53 per cent) of the 88 patients approached for QUEST A and 22 (61 per cent) of the 36 approached for QUEST B. Both trials closed to recruitment in December 2012, acknowledging the challenges of achieving satisfactory patient accrual.

CONCLUSION

Despite extensive efforts to overcome recruitment barriers, it was not feasible to reach timely recruitment targets within a feasibility study. Patient preferences for breast reconstruction types and timings were common, rendering patients unwilling to enter the trial.

Clinical practice guidelines for delirium management: potential application in palliative care

CONTEXT

Delirium occurs in patients across a wide array of health care settings. The extent to which formal management guidelines exist or are adaptable to palliative care is unclear.

OBJECTIVES

This review aims to 1) source published delirium management guidelines with potential relevance to palliative care settings, 2) discuss the process of guideline development, 3) appraise their clinical utility, and 4) outline the processes of their implementation and evaluation and make recommendations for future guideline development.

METHODS

We searched PubMed (1990-2013), Scopus, U.S. National Guideline Clearinghouse, Google, and relevant reference lists to identify published guidelines for the management of delirium. This was supplemented with multidisciplinary input from delirium researchers and other relevant stakeholders at an international delirium study planning meeting.

RESULTS

There is a paucity of high-level evidence for pharmacological and non-pharmacological interventions in the management of delirium in palliative care. However, multiple delirium guidelines for clinical practice have been developed, with recommendations derived from "expert opinion" for areas where research evidence is lacking. In addition to their potential benefits, limitations of clinical guidelines warrant consideration. Guidelines should be appraised and then adapted for use in a particular setting before implementation. Further research is needed on the evaluation of guidelines, as disseminated and implemented in a clinical setting, focusing on measurable outcomes in addition to their impact on quality of care.

CONCLUSION

Delirium clinical guidelines are available but the level of evidence is limited. More robust evidence is required for future guideline development.

Uncertainty and the Development of Evidence-Based Guidelines

This article explores how developers address uncertainty in the creation of an evidence-based guideline (EBG). As the aim of an EBG is to assist healthcare practitioners in situations of doubt, it is easy to assume that uncertainty has no place in guidelines. However, as we discovered, guideline development does not ignore uncertainty but seeks to accept it while establishing credible recommendations for healthcare. Dealing with omissions in knowledge, ignorance, or challenges in valuating different sorts of knowledge form the core of the work of guideline developers. Interviewing guideline developers, we found three types of valuation work: classifying studies, grading types of knowledge, and involving expertise and clinical practice. These methods have consequences for the credibility, and amount and kind of uncertainty EBGs can include.

Guidelines: is bigger better? A review of SIGN guidelines

OBJECTIVES

To quantify and analyse the quality of evidence that is presented in national guidelines.

SETTING

Levels of evidence used in all the current valid recommendations in the Scottish Intercollegiate Guideline Network (SIGN) guidelines were reviewed and statistically analysed.

OUTCOME MEASURES

The proportion of level D evidence used in each guideline and a statistical analysis.

METHOD

Data were collected from published guidelines available online to the public. SIGN methodology entails a professional group selected by a national organisation to develop each of these guidelines. Statistical analysis of the relationship between the number of guideline recommendations and the quality of evidence used in its recommendations was performed.

RESULT

The proportion of level D evidence increases with the number of recommendations made. This correlation is significant with Kendall's τ=0.22 (approximate 95% CI 0.008 to 0.45), p = 0.04; and Spearman ρ=0.22 (approximate 95% CI 0.02 to 0.57), p=0.04.

CONCLUSIONS

Practice guidelines should be brief and based on scientific evidence. Paradoxically the longest guidelines have the highest proportion of recommendations based on the lowest level of evidence. Guideline developers should be more aware of the need for brevity and a stricter application of evidence-based principles could achieve this. The findings support calls for a review of how evidence is used and presented in guidelines.

Appraisal tools for clinical practice guidelines: a systematic review

INTRODUCTION

Clinical practice guidelines can improve healthcare processes and patient outcomes, but are often of low quality. Guideline appraisal tools aim to help potential guideline users in assessing guideline quality. We conducted a systematic review of publications describing guideline appraisal tools in order to identify and compare existing tools.

METHODS

Among others we searched MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews from 1995 to May 2011 for relevant primary and secondary publications. We also handsearched the reference lists of relevant publications. On the basis of the available literature we firstly generated 34 items to be used in the comparison of appraisal tools and grouped them into thirteen quality dimensions. We then extracted formal characteristics as well as questions and statements of the appraisal tools and assigned them to the items.

RESULTS

We identified 40 different appraisal tools. They covered between three and thirteen of the thirteen possible quality dimensions and between three and 29 of the possible 34 items. The main focus of the appraisal tools were the quality dimensions "evaluation of evidence" (mentioned in 35 tools; 88%), "presentation of guideline content" (34 tools; 85%), "transferability" (33 tools; 83%), "independence" (32 tools; 80%), "scope" (30 tools; 75%), and "information retrieval" (29 tools; 73%). The quality dimensions "consideration of different perspectives" and "dissemination, implementation and evaluation of the guideline" were covered by only twenty (50%) and eighteen tools (45%) respectively.

CONCLUSIONS

Most guideline appraisal tools assess whether the literature search and the evaluation, synthesis and presentation of the evidence in guidelines follow the principles of evidence-based medicine. Although conflicts of interest and norms and values of guideline developers, as well as patient involvement, affect the trustworthiness of guidelines, they are currently insufficiently considered. Greater focus should be placed on these issues in the further development of guideline appraisal tools.