Improving the quality of health care: using international collaboration to inform guideline programmes by founding the Guidelines International Network (G-I-N)

Approaches to clinical guideline development in healthcare: a scoping review and document analysis

BACKGROUND

Over the past decade, an industry has emerged around Clinical Practice Guideline (CPG) development in healthcare, which has increased pressure on guideline-producing organisations to develop CPGs at an accelerated rate. These are intended to improve the quality of care provided to patients while containing healthcare costs and reducing variability in clinical practice. However, this has inadvertently led to discrepancies in CPG recommendations between health organisations, also challenging healthcare providers who rely on these for decision-making and to inform clinical care. From a global perspective, although some countries have initiated national protocols regarding developing, appraising and implementing high-quality CPGs, there remains no standardised approach to any aspect of CPG production.

METHODS

A scoping review of the literature and document analysis were conducted according to Joanna Brigg's Institute methodology for scoping reviews. This comprised two qualitative methods: a comprehensive review of the literature (using CINAHL, Scopus and PubMeD) and a document analysis of all national and international guideline development processes (manual search of health-related websites, national/international organisational health policies and documents).

RESULTS

A set of clear principles and processes were identified as crucial to CPG development, informing the planning, implementation and dissemination of recommendations. Fundamentally, two common goals were reported: to improve the quality and consistency of clinical practice (patient care) and to reduce the duplication or ratification of low-grade CPGs.

CONCLUSIONS

Consultation and communication between CPG working parties, including a wide range of representatives (including professional organisations, regional and local offices, and relevant national bodies) is essential. Further research is required to establish the feasibility of standardising the approach and disseminating the recommendations.

Adapting the depression component of WHO Mental Health Gap Intervention Guide (mhGAP-IG.v2) for primary care in Shenzhen, China: a DELPHI study

Background

Primary care doctors in Shenzhen, China are increasingly expected to identify and prevent depressive disorder; however, they have received limited mental health training and community healthcare centres (CHC) do not provide standardised protocols for the diagnosis and care of depressive disorder. The World Health Organization’s mental health gap intervention guide, version 2 (mhGAP-IG.v2) is a decision support tool for non-specialists for the assessment, management and follow-up of mental, neurological and substance use disorders (including depressive disorder). Given that mhGAP-IG.v2 is a generic tool, it requires adaptation to take account of cultural differences in depression presentation and unique characteristics of China’s emergent mental health system.

Methods

A two-round, web-based, Delphi survey was conducted. A panel of primary care doctors from Shenzhen, were invited to score their level of agreement with 199 statements (arranged across 10 domains) proposing changes to the content and structure of mhGAP-IG.v2 for use in Shenzhen. Consensus was predefined as 80% panelists providing a rating of either “somewhat agree/definitely agree”, or “definitely disagree/somewhat disagree” on a five-point scale for agreement.

Results

79% of statements received consensus with a mean score of 4.26 (i.e. “somewhat agree”). Agreed adaptations for mhGAP-IG.v2 included:- an assessment approach which considers a broader spectrum of depression symptoms and reflects the life course of disease; incorporating guidance for screening tool usage; clarifying physicians’ roles and including referral pathways for intersectorial care with strong family involvement; aligning drug treatment with national formularies; stronger emphasis of suicide prevention throughout all sections of the guide; contextualizing health education; reflecting a person-centred approach to care. Panelists chose to maintain diagnostic and treatment advice for bipolar patients experiencing a depressive episode as in the current guide.

Conclusions

An adapted mhGAP-IG.v2 for depression recognises China’s cultural and contextual needs for assessment guidance; unique primary healthcare system organization, priorities and treatment availability; and diverse psychosocial educational needs. An adapted mhGAP-IG.v2 could both inform the future training programs for primary care in Shenzhen and also offer an additional mental health resource for non-specialists in other countries.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13033-022-00523-0.

Quality of recent clinical practice guidelines in anaesthesia publications using the Appraisal of Guidelines for Research and Evaluation II instrument

Clinical practice guidelines are a valuable resource aiding medical decision-making based on scientific evidence. In anaesthesia, guidelines are increasing in both number and scope, influencing individual practice and shaping local departmental policy. The aim of this review is to assess the quality of clinical practice guidelines published in high impact anaesthesia journals over the past 5 yr using the internationally validated Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. A literature search was conducted in Scopus to identify all guidelines published in the top 10 anaesthesia journals as per Clarivate Analytics Impact Factor from 2016 and 2020. Fifty-one guidelines were included for analysis by five independent appraisers using AGREE II. Each guideline was assessed across six domains and 23 items. Individual domain scores were calculated with a threshold agreed via consensus to represent high-quality guidelines. There was a significant increase in overall score over time (P=0.041), driven by Domain 3 (Rigour of Development, P=0.046). The raw overall score for Domain 3, however, was low. The other domains performed as expected based on previous studies, with Domains 1, 4, and 6 achieving high scores and Domains 2 and 5 incurring poor ratings. Most guidelines studied involved international collaboration but emerged from a single professional society. Use of an appraisal tool was stated as high but poorly detailed. The improvement in the overall score of guidelines and rigour of development is promising; however, only seven guidelines met high-quality criteria, suggesting room for improvement for the overall integrity of guidelines in anaesthesia.

Consistent Definitions of Clinical Practice Guidelines, Consensus Statements, Position Statements, and Practice Alerts

An evidence-based approach to clinical decision-making for optimizing patient care is desirable because it promotes quality of care, improves patient safety, decreases medical errors, and reduces health care costs. Clinical practice recommendations are systematically developed documents regarding best practice for specific clinical management issues, which can assist care providers in their clinical decision-making. However, there is currently wide variation in the terminology used for such clinical practice recommendations. The aim of this article is to provide guidance to authors, reviewers, and editors on the definitions of terms commonly used for clinical practice recommendations. This is intended to improve transparency and clarity regarding the definitions of these terminologies.

Adapting evidence-based clinical practice guidelines at university teaching hospitals: A model for the Eastern Mediterranean Region

RATIONALE, AIMS, AND OBJECTIVES

Clinical practice guidelines (CPGs) are significant tools for evidence-based health care quality improvement. The CPG program at King Saud University was launched as a quality improvement program to fulfil the international accreditation standards. This program was a collaboration between the Research Chair for Evidence-Based Healthcare and Knowledge Translation and the Quality Management Department. This study aims to develop a fast-track method for adaptation of evidence-based CPGs and describe results of the program.

METHODS

Twenty-two clinical departments participated in the program. Following a CPGs awareness week directed to all health care professionals (HCPs), 22 teams were trained to set priorities, search, screen, assess, select, and customize the best available CPGs. The teams were technically supported by the program's CPG advisors. To address the local health care context, a modified version of the ADAPTE was used where recommendations were either accepted or rejected but not changed. A strict peer-review process for clinical content and methodology was employed.

RESULTS

In addition to raising awareness and building capacity, 35 CPGs were approved for implementation by March 2018. These CPGs were integrated with other existing projects such as accreditation, electronic medical records, performance management, and training and education. Preliminary implementation audits suggest a positive impact on patient outcomes. Leadership commitment was a strength, but the high turnover of the team members required frequent and extensive training for HCPs.

CONCLUSION

This model for CPG adaptation represents a quick, practical, economical method with a sense of ownership by staff. Using this modified version can be replicated in other countries to assess its validity.

Redeveloping the JBI Model of Evidence Based Healthcare

BACKGROUND

In 2005, Pearson et al. presented a developmental framework of evidence-based practice that sought to situate healthcare evidence and its role and use within the complexity of practice settings globally. A decade later, it was deemed timely to re-examine the Model and its component parts to determine whether they remain relevant and a true and accurate reflection of where the evidence-based movement is today.

METHODS

A two-phase process was employed for this project. Phase 1 involved a citation analysis, conducted using the index citation of the original source article on the Joanna Briggs Institute (JBI) Model by Pearson et al. The databases searched were Web of Science and Google Scholar from year of publication (2005) to July 2015. Duplicates and articles in languages other than English were removed, and all results were imported and combined in an Excel spreadsheet for review, coding and interpretation. Phase 2 (model revision) occurred in two parts. Part 1 involved revision of the Model by an internal working group. This revised version of the Model was then subjected to a process of focus group discussion (Part 2) that engaged staff of the Joanna Briggs Collaboration during the 2015 annual general meeting. These data were recorded then transcribed for review and consideration.

RESULTS

The citation analysis revealed that the Model was primarily utilized to conceptualize evidence and evidence-based healthcare, but that language used in relation to concepts within the Model was variable. Equally, the working group and focus group feedback confirmed that there was a need to ensure the language utilized in the Model was internationally appropriate and in line with current international trends. This feedback and analysis informed the revised version of the JBI Model.

CONCLUSION

Based on the citation analysis, working group and focus group feedback the new JBI Model for Evidence Based Healthcare attempts to utilize more internationally appropriate language to detail the intricacies of the relationships between systems and individuals across different settings and the need for contextual localization to enable policy makers and practitioners to make evidence-based decisions at the point of care.

Failure Mode and Effect Analysis (FMEA) may enhance implementation of clinical practice guidelines: An experience from the Middle East

RATIONALE, AIMS, AND OBJECTIVES

Implementation of clinical practice guidelines (CPGs) has been shown to reduce variation in practice and improve health care quality and patients' safety. There is a limited experience of CPG implementation (CPGI) in the Middle East. The CPG program in our institution was launched in 2009. The Quality Management department conducted a Failure Mode and Effect Analysis (FMEA) for further improvement of CPGI.

METHODS

This is a prospective study of a qualitative/quantitative design. Our FMEA included (1) process review and recording of the steps and activities of CPGI; (2) hazard analysis by recording activity-related failure modes and their effects, identification of actions required, assigned severity, occurrence, and detection scores for each failure mode and calculated the risk priority number (RPN) by using an online interactive FMEA tool; (3) planning: RPNs were prioritized, recommendations, and further planning for new interventions were identified; and (4) monitoring: after reduction or elimination of the failure mode. The calculated RPN will be compared with subsequent analysis in post-implementation phase.

RESULTS

The data were scrutinized from a feedback of quality team members using a FMEA framework to enhance the implementation of 29 adapted CPGs. The identified potential common failure modes with the highest RPN (≥ 80) included awareness/training activities, accessibility of CPGs, fewer advocates from clinical champions, and CPGs auditing. Actions included (1) organizing regular awareness activities, (2) making CPGs printed and electronic copies accessible, (3) encouraging senior practitioners to get involved in CPGI, and (4) enhancing CPGs auditing as part of the quality sustainability plan.

CONCLUSION

In our experience, FMEA could be a useful tool to enhance CPGI. It helped us to identify potential barriers and prepare relevant solutions.

A SYSTEMATIC APPROACH FOR ASSESSING, IN THE ABSENCE OF FULL EVIDENCE, WHETHER MULTICOMPONENT INTERVENTIONS CAN BE MORE COST-EFFECTIVE THAN SINGLE COMPONENT INTERVENTIONS

OBJECTIVES

Multicomponent interventions (MCIs), consisting of at least two interventions, are common in rehabilitation and other healthcare fields. When the effectiveness of the MCI versus that of its single interventions is comparable or unknown, evidence of their expected incremental cost-effectiveness can be helpful in deciding which intervention to recommend. As such evidence often is unavailable this study proposes an approach to estimate what is more cost-effective; the MCI or the single intervention(s).

METHODS

We reviewed the literature for potential methods. Of those identified, headroom analysis was selected as the most suitable basis for developing the approach, based on the criteria of being able to estimate the cost-effectiveness of the single interventions versus that of the MCI (a) within a limited time frame, (b) in the absence of full data, and (c) taking into account carry-over and interaction effects. We illustrated the approach with an MCI for cancer survivors.

RESULTS

The approach starts with analyzing the costs of the MCI. Given a specific willingness-to-pay-value, it is analyzed how much effectiveness the MCI would need to generate to be considered cost-effective, and if this is likely to be attained. Finally, the cost-effectiveness of the single interventions relative to the potential of the MCI for being cost-effective can be compared.

CONCLUSIONS

A systematic approach using headroom analysis was developed for estimating whether an MCI is likely to be more cost effective than one (or more) of its single interventions.

Neuropathic Pain Related with Spinal Disorders: A Systematic Review

Systematic literature review. To review the evidence from high-quality studies regarding the treatment of neuropathic pain originating specifically from spinal disorders. In general, treatment guidelines for neuropathic pain cover all its various causes, including medical disease, peripheral neuropathy, and cancer. However, the natural history of neuropathic pain originating from spinal disorders may differ from that of the pain originating from other causes or lesions. An expert research librarian used terms related to neuropathic pain and spinal disorders, disc herniation, stenosis, and spinal cord injury to search in MEDLINE, Embase, and Cochrane CENTRAL for primary research from January 2000 to October 2015. Among 2,313 potential studies of interest, 25 randomized controlled trials (RCTs) and 21 systematic reviews (SRs) were included in the analysis. The selection was decided based on the agreement of two orthopedic surgeons. There was a lack of evidence about medication for radiculopathy arising from disc herniation and stenosis, but intervention procedures, including epidural block, showed positive efficacy in radiculopathy and also limited efficacy in spinal stenosis. There was some evidence based on the short-term follow-up regarding surgery being superior to conservative treatments for radiculopathy and stenosis. There was limited evidence regarding the efficacy of pharmacological and electric or magnetic stimulation therapies for neuropathic pain after spinal cord injury. This review of RCTs and SRs with high-quality evidence found some evidence regarding the efficacy of various treatment modalities for neuropathic pain related specifically to spinal disorders. However, there is a need for much more supportive evidence.

[Cornerstones of quality assurance in medicine in Germany. Important impulse for the situation in treatment of rheumatism]

The recently passed German hospital structure act (Krankenhausstrukturgesetz) stresses the immense importance of quality for the medical care of the population. How can inpatient and outpatient treatment in the field of rheumatology be improved and how can this be assessed? A very important basis for such measurement approaches are quality indicators, i.e. parameters that indicate to what degree a certain level of quality has already been reached or is planned to be reached in the future. The work performed by the German Rheumatism Research Center (DRFZ) and the Association of Rheumatological Acute Clinics (VRA) in Germany has already used certain quality indicators and this topic has been recently described elsewhere. International quality indicators have also been published in recent years, all for rheumatoid arthritis (RA), the most prevalent inflammatory rheumatic disease and are the central subject of this article. This overview of proposed instruments for quality assessment in rheumatology is intended to initiate a broad discussion on the subject of quality of rheumatological care in Germany.

[Quality of German medical services: a review]

In the current draft of the law on the reform of the support structures of hospital provision (German Hospital Structure Law) the future quality of provision is highly significant. Quality assurance measures are mandatory for hospitals. The Federal General Committee was legally charged with developing the relevant quality indicators for structural, procedural and outcome quality that are designed to form the criteria and the basis for planning decisions in the federal states. This involves a paradigm shift in quality assurance measures in hospitals. In the future, subject to the verified quality, this should have an influence on hospital planning, and the funding or regulation of hospital departments should also adhere to this prescribed quality. This review reveals the course of quality or quality assurance measures in medical services in Germany. The status of the institutions responsible for the quality of care in hospitals and the significance of quality indicators are explained.

Changing Provider Behavior in the Context of Chronic Disease Management: Focus on Clinical Inertia

Widespread acceptance of evidence-based medicine has led to the proliferation of clinical practice guidelines as the primary mode of communicating current best practices across a range of chronic diseases. Despite overwhelming evidence supporting the benefits of their use, there is a long history of poor uptake by providers. Nonadherence to clinical practice guidelines is referred to as clinical inertia and represents provider failure to initiate or intensify treatment despite a clear indication to do so. Here we review evidence for the ubiquity of clinical inertia across a variety of chronic health conditions, as well as the organizational and system, patient, and provider factors that serve to maintain it. Limitations are highlighted in the emerging literature examining interventions to reduce clinical inertia. An evidence-based framework to address these limitations is proposed that uses behavior change theory and advocates for shared decision making and enhanced guideline development and dissemination.

Comparison of international guidelines on the accompanying therapy for advanced gastric cancer: reasons for the differences

The purpose of this study was to determine if international guidelines differ in their recommendations concerning additive therapy for advanced, but potentially curable, gastric cancer. A systematic search of the English and German literature was conducted in the databases Medline, Cochrane Database, Embase, and PubMed. The search terms used were 'guidelines gastric cancer,' 'guidelines stomach cancer,' and 'Leitlinien Magenkarzinom.' Six different guidelines published after January 1, 2010, in which the tumors were classified according to the seventh edition of the TNM system (2010), were identified. Although the examined guidelines were based on the same study results, their recommendations concerning accompanying therapy for gastric cancer differ considerably. While perioperative chemotherapy is recommended in Germany, Great Britain, and large parts of Europe, postoperative adjuvant radiochemotherapy or perioperative chemotherapy is recommended in the USA and Canada. In Japan, postoperative adjuvant chemotherapy is recommended.The results of identical studies were interpreted differently in different countries. Since considerable effort is required for each country to separately test relevant studies for their validity and suitability, an international cooperation could simplify the creation of a common basis for guidelines and contribute to improved comparability of international guidelines.

Addressing implementation challenges during guideline development - a case study of Swedish national guidelines for methods of preventing disease

Background

Many of the world’s life threatening diseases (e.g. cancer, heart disease, stroke) could be prevented by eliminating life-style habits such as tobacco use, unhealthy diet, physical inactivity and excessive alcohol use. Incorporating evidence-based research on methods to change unhealthy lifestyle habits in clinical practice would be equally valuable. However gaps between guideline development and implementation are well documented, with implications for health care quality, safety and effectiveness. The development phase of guidelines has been shown to be important both for the quality in guideline content and for the success of implementation. There are, however, indications that guidelines related to general disease prevention methods encounter specific barriers compared to guidelines that are diagnosis-specific. In 2011 the Swedish National board for Health and Welfare launched guidelines with a preventive scope. The aim of this study was to investigate how implementation challenges were addressed during the development process of these disease preventive guidelines.

Methods

Seven semi-structured interviews were conducted with members of the guideline development management group. Archival data detailing the guideline development process were also collected and used in the analysis. Qualitative data were analysed using content analysis as the analytical framework.

Results

The study identified several strategies and approaches that were used to address implementation challenges during guideline development. Four themes emerged from the analysis: broad agreements and consensus about scope and purpose; a formalized and structured development procedure; systematic and active involvement of stakeholders; and openness and transparency in the specific guideline development procedure. Additional factors concerning the scope of prevention and the work environment of guideline developers were perceived to influence the possibilities to address implementation issues.

Conclusions

This case study provides examples of how guideline developers perceive and approach the issue of implementation during the development and early launch of prevention guidelines. Models for guideline development could benefit from an initial assessment of how the guideline topic, its target context and stakeholders will affect the upcoming implementation.

Adaptation, evaluation, and updating of guidelines: article 14 in Integrating and coordinating efforts in COPD guideline development. An official ATS/ERS workshop report

INTRODUCTION

Professional societies, like many other organizations, have recognized the need to use more rigorous processes to ensure that health care recommendations are informed by the best available research evidence. This is the last of a series of 14 articles that methodologists and researchers from around the world have prepared to advise guideline developers in respiratory and other diseases on how to achieve this. We updated a review of the literature on guideline adaptation, evaluation, and updating, focusing on four key questions.

METHODS

In this review we addressed the following questions. (1) Which high-quality guidelines on chronic obstructive pulmonary disease (COPD) are available? (2) How should guidelines be adapted to the user's context and culture? (3) How should the use of guidelines be evaluated in clinical practice? and (4) How should guidelines be efficiently kept up-to-date? We did not conduct systematic reviews ourselves. We relied on a literature review published in 2006 and on a manual produced by the ADAPTE Collaboration to inform our judgments, as well as our collective experience and workshop discussions.

RESULTS AND DISCUSSION

Guideline adaptation can be seen as an alternative to de novo development and as part of an implementation process, taking into consideration the user's own context. A systematic approach should be followed to ensure high quality of the resulting guidance. On the topic of COPD, many guidelines are available. Guidelines of the Global Initiative for Chronic Obstructive Lung Disease and of the American Thoracic Society and European Respiratory Society are particularly well-suited for adaptation. The adaptation process includes (1) definition of specific questions that need to be answered by the guideline; (2) assessment of guideline quality; (3) assessment of the clinical content, validity, acceptability, applicability, and transferability of the recommendations; and (4) decisions about adoption or adaptation of the recommendations. The use of the guidelines in practice can be measured with performance indicators. Adverse effects of strict adherence to guideline recommendations should be prevented, in particular when the improvement of patient outcomes is unclear. COPD guidelines should be updated at least every 2 years. Collaboration between COPD guideline developers is recommended to prevent duplication of effort.

Simultaneous development of guidelines and quality indicators -- how do guideline groups act? A worldwide survey

PURPOSE

The purpose of this paper is to examine the question of how official bodies, health care organisations, and professional associations deal with the absence of a methodological gold standard for the simultaneous development of clinical practice guidelines and quality indicators, what procedures they use and what they feel are major strengths and limitations of their methods.

DESIGN/METHODOLOGY/APPROACH

The authors conducted a web-based survey among 90 organisational members of the Guidelines International Network (G-I-N) representing 34 countries from Africa, America, Asia, Europe and Oceania. All organisational G-I-N members were invited to participate in the survey by following a link provided in the invitation e-mail.

FINDINGS

The responses of 24 organisations were included in the final analysis. The results indicate a broad variability in the approaches and methods used to develop quality indicators and guidelines simultaneously. The answers of the participants indicated a lack of formal procedures for the simultaneous development. Formal procedures exist in only about half of the participating organisations. In addition, piloting or evaluation of the procedures is almost completely missing. Significantly, respondents mainly reported that the procedure used in their organisation "could certainly be more rigorous". Besides various strengths, participants reported a considerable number of limitations of the development processes they use.

ORIGINALITY/VALUE

This survey among G-I-N members -- despite limitations -- gives helpful insights in the state of the simultaneous development of quality indicators and clinical practice guidelines and underlines the need for future activities in methodological standard development and quality improvement of these processes.

A systematic approach for uptake of evidence on sex-specific issues in guidelines--a pilot study

RATIONALE, AIMS AND OBJECTIVES

Increasing evidence indicates that sex-specific issues may have impact on prevention, diagnosis, or treatment. These issues are not systematically considered during the development of Dutch clinical practice guidelines. The aim of this study is to identify how members of guideline development groups discuss sex-specific evidence, and whether and how the outcomes of these discussions are reflected in the guideline.

METHODS

Six guideline development committees (GDCs) were studied. Each committee was supported by a staff member from the guideline organization who was trained and received feedback to facilitate uptake of evidence on sex differences in the process of guideline development. Non-participant observation and transcription of audio recordings from 22 GDC meetings were performed. Content analysis of meeting transcripts and guidelines were studied to analyse characteristics of discussion episodes on sex-specific research data-based issues (subject matter, initiator and group approach towards the topic and themes) and whether or not conclusions on evidence were reflected in the final guideline text.

RESULTS

Of the 87 identified discussion episodes, 68 dealt with sex-specific research evidence potentially relevant to guidelines. Respectively 51%, 28% and 21% of the latter episodes were initiated by committee members, staff members and chairpersons. Group approaches towards the subject matter were generally positive. Data from 60% of those episodes were reflected in the final guideline text. Sex-specific data on reproductive issues were more often discussed and reflected in guideline texts than data on other health issues. Discussion episodes on sex-specific evidence initiated by chairpersons were most often reflected in the guidelines.

CONCLUSIONS

This pilot study indicates that GDCs regularly focused on sex-specific issues. The participation of a trained staff member contributed to this.

A Web-based archive of systematic review data

Systematic reviews have become increasingly critical to informing healthcare policy; however, they remain a time-consuming and labor-intensive activity. The extraction of data from constituent studies comprises a significant portion of this effort, an activity which is often needlessly duplicated, such as when attempting to update a previously conducted review or in reviews of overlapping topics.In order to address these inefficiencies, and to improve the speed and quality of healthcare policy- and decision-making, we have initiated the development of the Systematic Review Data Repository, an open collaborative Web-based repository of systematic review data. As envisioned, this resource would serve as both a central archive and data extraction tool, shared among and freely accessible to organizations producing systematic reviews worldwide. A suite of easy-to-use software tools with a Web frontend would enable researchers to seamlessly search for and incorporate previously deposited data into their own reviews, as well as contribute their own.In developing this resource, we identified a number of technical and non-technical challenges, as well as devised a number of potential solutions, including proposals for systems and software tools to assure data quality, stratify and control user access effectively and flexibly accommodate all manner of study data, as well as means by which to govern and foster adoption of this new resource.Herein we provide an account of the rationale and development of the Systematic Review Data Repository thus far, as well as outline its future trajectory.

Prospective systematic review registration: perspective from the Guidelines International Network (G-I-N)

Clinical practice and public health guidelines are important tools for translating research findings into practice with the aim of assisting health practitioners as well as patients and consumers in health behavior and healthcare decision-making. Numerous programs for guideline development exist around the world, with growing international collaboration to improve their quality. One of the key features in developing trustworthy guidelines is that recommendations should be based on high-quality systematic reviews of the best available evidence. The review process used by guideline developers to identify and grade relevant evidence for developing recommendations should be systematic, transparent and unbiased. In this paper, we provide an overview of current international developments in the field of practice guidelines and methods to develop guidelines, with a specific focus on the role of systematic reviews. The Guidelines International Network (G-I-N) aims to stimulate collaboration between guideline developers and systematic reviewers to optimize the use of available evidence in guideline development and to increase efficiency in the guideline development process. Considering the significant benefit of systematic reviews for the guideline community, the G-I-N Board of Trustees supports the international prospective register of systematic reviews (PROSPERO) initiative. G-I-N also recently launched a Data Extraction Resource (GINDER) to present and share data extracted from individual studies in a standardized template. PROSPERO and GINDER are complementary tools to enhance collaboration between guideline developers and systematic reviewers to allow for alignment of activities and a reduction in duplication of effort.

A national model for developing, implementing, and evaluating evidence-based guidelines for prehospital care

In 2007, the Institute of Medicine's (IOM's) Committee on the Future of Emergency Care recommended that a multidisciplinary panel establish a model for developing evidence-based protocols for the treatment of emergency medical systems (EMS) patients. In response, the National EMS Advisory Council (NEMSAC) and the Federal Interagency Committee on EMS (FICEMS) convened a panel of multidisciplinary experts to review current strategies for developing evidence-based guidelines (EBGs) and to propose a model for developing such guidelines for the prehospital milieu. This paper describes the eight-step model endorsed by FICEMS, NEMSAC, and a panel of EMS and evidence-based medicine experts. According to the model, prehospital EBG development would begin with the input of evidence from various external sources. Potential EBG topics would be suggested following a preliminary evidentiary review; those topics with sufficient extant foundational evidence would be selected for development. Next, the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology would be used to determine a quality-of-evidence rating and a strength of recommendation related to the patient care guidelines. More specific, contextualized patient care protocols would then be generated and disseminated to the EMS community. After educating EMS professionals using targeted teaching materials, the protocols would be implemented in local EMS systems. Finally, effectiveness and uptake would be measured with integrated quality improvement and outcomes monitoring systems. The constituencies and experts involved in the model development process concluded that the use of such transparent, objective, and scientifically rigorous guidelines could significantly increase the quality of EMS care in the future.

[Guidelines and guideline research. Overview and state of guideline implementation in medical rehabilitation]

"Guideline research" is understood here to be the area of healthcare research that deals with the methodology and evaluation of processes for developing, implementing, assessing, and evaluating guidelines. For example, guideline research deals with the selection of adequate implementation strategies and the proof of the effectiveness and efficiency of the implementation of guidelines. The current data situation does not allow any reliable statements to be made about whether and to what extent the health-related outcome for patients is actually improved by implementing guidelines. For medical rehabilitation, there are a number of guidelines which appear to be just as good with respect to quality as the guidelines for acute medicine. However, there is a need for improvement in the quality criteria for methods. Rehab-related guidelines and therapy standards can be found in the AWMF guidelines, in the program for national healthcare guidelines, and in the rehabilitation quality assurance of the German Pension Fund. Guideline research in rehabilitation should concentrate on topics that arise from the specific situation of this area of healthcare, e.g., development of interdisciplinary guidelines, applicability of guidelines for multiple diseases, or possibility of evidence-based guidelines for complex interventions.

Schizophrenia guidelines across the world: a selective review and comparison

Treatment guidelines provide evidence-based recommendations to assist practitioners in specific clinical situations. They are a major tool to assure and enhance treatment quality and to overcome existing disparities. However, guideline quality itself varies and needs to be considered. Based on a former review, schizophrenia guidelines with high methodological quality were identified and examined regarding updated versions. Five guidelines were selected, of which three updates have been newly evaluated with the AGREE instrument. In addition, clinical content regarding seven core topics in schizophrenia treatment decisions was compared. Guideline quality on average is good, with highest AGREE scores for the NICE guideline. Updating of the German guideline resulted in noticeable quality improvements. Regarding content, recommendations largely correspond in five areas across guidelines, whereas discrepancies or vagueness exist in two areas due to newly emerging (drug choice) or still restricted evidence (duration of antipsychotic treatment). There are increasing efforts to develop guidelines with improved quality. Also, there is a need to equalize and improve healthcare quality across countries. Since many formal and content-related issues are 'universal', development of trans-national guidelines seems indicated. Nevertheless, core guideline recommendations should be adapted to regional conditions using available tools for adaptation.

Translation of hypertension treatment guidelines into practice: a review of implementation

Compared with the history of national guideline development, the science attached to implementation of guidelines is relatively new. Effectiveness of a highly evidence-based guideline, such as the 8th Joint National Committee recommendations on the treatment of high blood pressure, depends on successful translation into clinical practice. Implementation relies on several steps: clear and executable guideline language, audit and feedback attached to education of practitioners charged with carrying out the guidelines, team-based care delivery, credibility of blood pressure measurement, and measures to address therapeutic inertia and medication adherence. An evolving role of the electronic health record and patient empowerment are developments that will further promote implementation of the hypertension guideline. Further research will be needed to assess the efficacy and cost effectiveness of various implementation tools and strategies.

[Do patients participate in the development of clinical guidelines in Norway?]

BACKGROUND

The National Health Plan (2007-2010) establishes that users should participate in development of all parts of the health services. We have investigated whether and how patients participate in development of guidelines in Norway.

MATERIAL AND METHODS

Nine doctors and one nurse, trained in the AGREE instrument (an international tool for evaluation of clinical guidelines), evaluated patient involvement in development of key guidelines in Norway, on a scale from 1 (patient views not mentioned) to 4 (patients participate).

RESULTS

127 guidelines (published in the period 2000-2009) were assessed. The average score for extent of patient involvement was 1.8. Guidelines from public institutions scored higher than those developed by professional medical organizations; mean 2.4 (95 % CI 2.2-2.7) versus 1.5 (1.2-1.7). Guidelines on cancer, mental health, musculoskeletal disorders and pediatrics had the highest scores. There were no differences between older (2000-05) and more recent (2006-09) guidelines.

INTERPRETATION

Norwegian guidelines developers seldom involve patients in guideline development. Patient views are mainly not taken into account in literature searches or systematic collection of information.

[Perspectives in guideline development and implementation in Germany]

Guidelines are important tools for improving knowledge management, processes and outcomes in health care. They aim to assisst both the clinical and the patient decision-making process, particularly in those areas of health care where considerable variation or potential for improvement exist. However, guidelines are often subject to substantial criticism by practicing clinicians. A prerequisite to improving the acceptance of guidelines is a systematic and methodically sound approach in guideline development. The German instrument for methodological guideline appraisal, DELBI, is intended to assist both guideline developers and users. However, this alone is insufficient. Implementation is a process requiring multifaceted strategies to promote behavior change. These include the provision of assistance for local adaptation and well-defined quality indicators for monitoring guideline adherence and quality of care. Additionally, possible links to existing quality management activities should be taken into account to avoid duplication of efforts.

[Promoting patient-oriented dementia research - current issues in the German Centre for Neurodegenerative Diseases at the Witten/Herdecke University]

BACKGROUND AND OBJECTIVE

caring for people with dementia presents a growing challenge in an ageing society. We urgently need innovative future-oriented concepts of evidence-based health care which would improve the care for people with dementia, even under adverse circumstances. The German Center for Neurodegenerative Diseases (DZNE) in Witten is willing to meet this challenge.

FOCUS OF RESEARCH

the DZNE in Witten supports interdisciplinary research and houses three scientific work groups acting in close co-operation and focusing on 1) care structures, 2) care interventions, and 3) knowledge circulation and implementation research. A comprehensive project plan focuses on people with dementia's perspective in the early stages of the disease. It intends to investigate their needs, requirements und activities as a basis for the development of appropriate concepts. Apart from specific research questions methodological issues arising from the complexity of the subject are of interest.

DISCUSSION

the institutional funding of the location offers an unparalleled opportunity to plan long-term and more complex projects. This might lead to a close co-operation with the Witten/Herdecke University, where health care research is of particular relevance.

Nurses' experiences of guideline implementation: a focus group study

AIMS

The aim of the study was to address the following questions: What kind of experiences do primary care nurses have of guideline implementation? What do nurses think are the most important factors affecting the adoption of guidelines?

BACKGROUND

The implementation of clinical guidelines seems to be dependent on multiple context-specific factors. This study sets out to explore the experiences of primary care nurses concerning guideline implementation.

DESIGN

Qualitative interview.

METHODS

Data were generated by four focus group interviews involving nurses working in out-patient services in primary health centres in Finland. Purposive sampling was used to select health centres. Inductive content analysis was used to identify themes emerging from the data.

RESULTS

Four main groups of factors were identified from the analysis of data: (i) factors related to the organisation, (ii) factors related to nurses, (iii) factors related to the anticipated consequences and (iv) factors related to the patient group. Nurses' awareness and acceptance of guidelines and the anticipated positive consequences facilitate the implementation of guidelines. Organisational support, especially the adapting of guidelines to local circumstances, seems to be crucial for successful implementation.

CONCLUSIONS

Clinical guidelines can be promising tools in enhancing evidence-based nursing practice, as nurses see them as practical work tools in patient care and so are willing to adopt them. However, support from management and physicians is needed to ensure the successful implementation of guidelines into nursing practices.

RELEVANCE TO CLINICAL PRACTICE

Based on the findings of this study and previous knowledge of guideline implementation some practical recommendations are suggested. Select the most relevant guidelines to clinical practice, organise the adaptation of guidelines to local circumstances, inform all practitioners involved in treatment and give clear instructions for the adoption of the guidelines.

[Principles of the developmental process and implementation of guidelines. An update]

Guidelines are important tools to improve knowledge management, processes and outcomes in health care. Their function is to assist professionals and patients decisions about appropriate and effective practice, especially in those areas of health care where considerable variation or potential for improvement exists. The achievement of a favourable impact necessitates both a systematic and methodically sound approach in the development of guidelines. The German Instrument for Methodological Guideline Appraisal, an adopted and supplemented version of the AGREE (Appraisal of Guidelines Research and Evaluation) instrument, provides 34 quality criteria guideline developers should take into account. However, the impact of guidelines is not only determined by methodological soundness but also by the choice of the guideline topic (need for a guideline), by its dissemination (accessibility) and implementation (acceptance and use). Finally, this impact must be monitored by means of guideline-based quality indicators.

[The GRADE System. An international approach to standardize the graduation of evidence and recommendations in guidelines]

Clinical practice guidelines have become an important source of information to support clinicians in the management of individual patients. However, current guideline methods have limitations that include the lack of separating the quality of evidence from the strength of recommendations. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) working group, an international collaboration of guideline developers, methodologists, and clinicians have developed a system that addresses these shortcomings. Core elements include transparent methodology for grading the quality of evidence, the distinction between quality of the evidence and strength of a recommendation, an explicit balancing of benefits and harms of health care interventions, an explicit recognition of the values and preferences that underlie recommendations. The GRADE system has been piloted in various practice settings to ensure that it captures the complexity involved in evidence assessment and grading recommendations while maintaining simplicity and practicality. Many guideline organizations and medical societies have endorsed the system and adopted it for their guideline processes.

Production and quality of clinical practice guidelines in Argentina (1994-2004): a cross-sectional study

Background

In the last decades, a sustained increment of Clinical Practice Guidelines (CPG) production in the world has been accompanied by a growing concern about their quality. Many studies related to quality assessment of guidelines produced in High Income Countries were published; however, evidence on this topic is scarce in Low and Middle Income Countries (LMIC). The objectives of this research were: a) to describe guideline production in Argentina at different levels of the health system (macro, meso and micro) from 1994 to 2004; and b) to assess their quality by using the AGREE instrument.

Methods

A cross-sectional study was undertaken to describe guidelines production in Argentina between 1994 and 2004. CPG were identified through Internet and electronic databases (MEDLINE and LILACS). Explicit inclusion and exclusion criteria were used to select guidelines. Each CPG was independently assessed by two reviewers using the AGREE instrument. Domain scores were calculated as recommended by the AGREE Collaboration. The internal consistency of each domain was evaluated using Cronbach's alpha and inter-observer agreement by the Intraclass Correlation Coefficient (ICC).

Results

A total amount of 431 potential CPG were identified, but only 144 were considered CPG. At the end, 101 CPG were included for further assessment. Median standardized score for each domain were: scope = 39%; stakeholder involvement = 13%; rigour of development = 10%; clarity = 42%; applicability = 6%; editorial independence = 0%. Only 22 CPG were recommended with modifications by both appraisers. ICC and Cronbach's alpha for each domain were in all cases moderate or high (greater than 0.40), except for editorial independence.

Conclusion

This study has systematically employed the AGREE instrument for the critical assessment of guidelines produced in a LMIC. Guideline development and diffusion in Argentina from 1994 to 2004 shows a constant increment, although quality of reporting did not improve; moreover, in some aspects it seemed to decline. Much room for improvement of the guideline development process was found at all levels of the health system.

Inefficacy of different strategies to improve guideline awareness - 5-year follow-up of the hypertension evaluation project (HEP)

Background

In spite of numerous guidelines for evidence based diagnostic and therapy adequate knowledge of current recommendations is disappointingly low. In the Hypertension Evaluation Project (HEP I) we showed that awareness of national hypertension guidelines under German practitioners was less than 25% in the year 2000. This indicates the need for efficient strategies to relevantly improve guideline awareness.

Methods

To asses different tools for amending guideline knowledge we used three strategies (guideline in print, interactive guideline, expert seminars) to train 8325 randomised physicians, who had participated in the HEP I trial. Guideline knowledge of the trained physicians was again tested with the HEP questionnaire and compared to a control group of HEP I physicians.

Results

The return rate of questionnaires was 57.9% without a significant distinction between the groups. Overall guideline awareness was still low but remarkably improved compared to the results of HEP I (37.1% vs. 23.7%, p < 0.0001). There was no difference between the trained physicians and the control group (35.8% and 35.9% vs. 39.7%, p = n.s.).

Conclusion

We investigated the influence of different strategies to improve guideline awareness among German physicians. None of our interventions (guideline in print, interactive guideline, expert seminars) brought a notable benefit compared to control group. However, overall knowledge of guideline contents increased from 23.7% to 37.1% over five years. Therefore, other probably multimodal interventions are necessary to significantly improve guideline awareness beyond spontaneous advancement.

Trial Registration

ISRCTN53383289

The methodological quality of clinical guidelines of the European Society of Human Reproduction and Embryology (ESHRE)

BACKGROUND

Clinical practice guidelines bridge the gap between the evidence from literature and clinical practice, and they may provide guidance in ethical, legal and societal dilemmas. To explore the potentials for future international guideline development within the field of human reproduction and embryology, we assessed the quality of existing guidelines produced by the European Society of Human Reproduction and Embryology (ESHRE).

METHODS

We systematically searched for the ESHRE guidelines produced after 1996 in electronic databases and on the Internet. Subsequently, we assessed the methodological quality of these guidelines using the validated Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument.

RESULTS

The overall methodological quality of most of the 11 selected ESHRE guidelines was poor. Most of the guidelines scored <30% in the domains of 'stakeholder involvement', 'rigour of development', 'applicability' and 'editorial independence'. Only one guideline was rated 'strongly recommended'.

CONCLUSIONS

The methodological quality of the guidelines produced under the auspices of ESHRE can be improved. We suggest a systematic, up-to-date methodology, investment in guideline development specialists, systematic quality control and the incorporation of indicator development. Furthermore, attention should be paid to the document nomenclature, and an ESHRE guidelines' summary on a special part of the ESHRE website would be a good initiative.