Ananda Chatterjee

Guideline uptake is influenced by six implementability domains for creating and communicating guidelines: a realist review

OBJECTIVES To identify factors associated with the implementability of clinical practice guidelines (CPGs) and to determine what characteristics improve their uptake. STUDY DESIGN AND SETTING We conducted a realist review, which involved searching multiple sources (eg, databases, experts) to determine what about guideline implementability works, for whom, and under what circumstances. Two sets of reviewers independently screened abstracts and extracted data from 278 included studies. Analysis involved the development of a codebook of definitions, validation of data, and development of hierarchical narratives to explain guideline implementability. RESULTS We found that guideline implementability is associated with two broad goals in guideline development: (1) creation of guideline content, which involves addressing the domains of stakeholder involvement in CPGs, evidence synthesis, considered judgment (eg, clinical applicability), and implementation feasibility and (2) the effective communication of this content, which involves domains related to fine-tuning the CPGs message (using simple, clear, and persuasive language) and format. CONCLUSION Our work represents a comprehensive and interdisciplinary effort toward better understanding, which attributes of guidelines have the potential to improve uptake in clinical practice. We also created codebooks and narratives of key concepts, which can be used to create tools for developing better guidelines to promote better care.

The development of a guideline implementability tool (GUIDE-IT): a qualitative study of family physician perspectives

BackgroundThe potential of clinical practice guidelines has not been realized due to inconsistent adoption in clinical practice. Optimising intrinsic characteristics of guidelines (e.g., its wording and format) that are associated with uptake (as perceived by their end users) may have potential. Using findings from a realist review on guideline uptake and consultation with experts in guideline development, we designed a conceptual version of a future tool called Guideline Implementability Tool (GUIDE-IT). The tool will aim to involve family physicians in the guideline development process by providing a process to assess draft guideline recommendations. This feedback will then be given back to developers to consider when finalizing the recommendations. As guideline characteristics are best assessed by end-users, the objectives of the current study were to explore how family physicians perceive guideline implementability, and to determine what components should comprise the final GUIDE-IT prototype.MethodsWe conducted a qualitative study with family physicians inToronto, Ontario. Two experienced investigators conducted one-hour interviews with family physicians using a semi-structured interview guide to 1) elicit feedback on perceptions on guideline implementability; 2) to generate a discussion in response to three draft recommendations; and 3) to provide feedback on the conceptual GUIDE-IT. Sessions were audio taped and transcribed verbatim. Data collection and analysis were guided by content analyses.Results20 family physicians participated. They perceived guideline uptake according to facilitators and barriers across 6 categories of guideline implementability (format, content, language, usability, development, and the practice environment). Participants’ feedback on 3 draft guideline recommendations were grouped according to guideline perception, cognition, and agreement. When asked to comment on GUIDE-IT, most respondents believed that the tool would be useful, but urged to involve “regular” or community family physicians in the process, and suggested that an online system would be the most efficient way to deliver it.ConclusionsOur study identified facilitators and barriers of guideline implementability from the perspective of community and academic family physicians that will be used to build our GUIDE-IT prototype. Our findings build on current knowledge by showing that family physicians perceive guideline uptake mostly according to factors that are in the control of guideline developers.

Making sense of complex data: a mapping process for analyzing findings of a realist review on guideline implementability

BackgroundRealist reviews offer a rigorous method to analyze heterogeneous data emerging from multiple disciplines as a means to develop new concepts, understand the relationships between them, and identify the evidentiary base underpinning them. However, emerging synthesis methods such as the Realist Review are not well operationalized and may be difficult for the novice researcher to grasp. The objective of this paper is to describe the development of an analytic process to organize and synthesize data from a realist review.MethodsClinical practice guidelines have had an inconsistent and modest impact on clinical practice, which may in part be due to limitations in their design. This study illustrates the development of a transparent method for organizing and analyzing a complex data set informed by a Realist Review on guideline implementability to better understand the characteristics of guidelines that affect their uptake in practice (e.g., clarity, format). The data organization method consisted of 4 levels of refinement: 1) extraction and 2) organization of data; 3) creation of a conceptual map of guideline implementability; and 4) the development of a codebook of definitions.ResultsThis new method is comprised of four steps: data extraction, data organization, development of a conceptual map, and operationalization vis-a-vis a codebook. Applying this method, we extracted 1736 guideline attributes from 278 articles into a consensus-based set of categories, and collapsed them into 5 core conceptual domains for our guideline implementability map: Language, Format, Rigor of development, Feasibility, Decision-making.ConclusionsThis study advances analysis methods by offering a systematic approach to analyzing complex data sets where the goals are to condense, organize and identify relationships.

Format guidelines to make them vivid, intuitive, and visual: use simple formatting rules to optimize usability and accessibility of clinical practice guidelines.

Aim:We present simple formatting rules derived from an extensive literature review that can improve the format of clinical practice guidelines (CPGs), and potentially increase the likelihood of being used. Methods:We recently conducted a review of the literature from medicine, psychology, design, and human factors engineering on characteristics of guidelines that are associated with their use in practice, covering both the creation and communication of content. The formatting rules described in this article are derived from that review. Results:The formatting rules are grouped into three categories that can be easily applied to CPGs: first, Vivid: make it stand out; second, Intuitive: match it to the audiences expectations, and third, Visual: use alternatives to text. We highlight rules supported by our broad literature review and provide specific ‘how to’ recommendations for individuals and groups developing evidence-based materials for clinicians. Conclusion:The way text documents are formatted influences their accessibility and usability. Optimizing the formatting of CPGs is a relatively inexpensive intervention and can be used to facilitate the dissemination of evidence in healthcare. Applying simple formatting principles to make documents more vivid, intuitive, and visual is a practical approach that has the potential to influence the usability of guidelines and to influence the extent to which guidelines are read, remembered, and used in practice.

How can Canadian guideline recommendations be tested

The developers of clinical practice guidelines invest substantial resources to produce and disseminate recommendations in an attempt to improve patient care. This process involves reviewing large bodies of sometimes conflicting evidence, converting the evidence into actionable and feasible

265WS Improving Guideline Implementability With Guide-M (Guideline Implementability For Decision Excellence Model): An Interactive Workshop

Background We developed a framework of guideline uptake called GuIDE-M (Guideline Implementability for Decision Excellence-Model) based on an extensive literature review. It describes four domains covering guideline content to optimise the implementability of recommendations (Stakeholder development, Evidence synthesis, Considered Judgement and Feasibility) and two domains related to communication of content (Language and Format). Objectives/Goal (1) To learn about GuIDE-M, (2) To conduct an assessment of participants’ current use of the GuIDE-M domains in guideline development or assessment and (3) To determine priorities for tool development to operationalize GuIDE-M domains. Target Group, Suggested Audience Guideline developers, guideline users and researchers. [5] Description of the Workshop and Methods used to Facilitate Interactions (1) Introduction (15 minutes). A brief foundational overview of GuIDE-M. (2) Facilitated Assessment (60 minutes). Participants will break into small groups to discuss one or more of the domains in GuIDE-M. There they will (a) conduct a more detailed review of the domain, (b) assess the extent to which their guideline-related activities align with GuIDE-M principles, (c) reflect on the extent to which improving in the area is a priority, (d) discuss methods and available tools to operationalize the domain concepts, and (e) explore the types of tool(s) that should be developed to incorporate domain concepts into guideline development. Participants will be invited to remain involved as evaluators, pilot-testers and developers of these tools. The facilitated assessment will happen twice (2 x 30 minutes) to allow participants to focus on two of the GuIDE-M domains. (3) Wrap-Up (15 minutes).

P081 Design Of Physician Printed Educational Materials: Making Good Ideas Stick

Background It is difficult to communicate new and complex clinical evidence to physicians already experiencing information overload. Proper use of design principles may increase uptake of guidelines and other printed educational materials (PEM) and improve practice. Objectives We aimed to determine whether physician-oriented PEMs are created in accordance with design principles. Methods We analysed PEMs identified in a 2012 Cochrane review of their effect on professional and patient outcomes and developed a checklist of design principles based on a literature review of clinical guideline implementability. Two analysts independently evaluated each PEM to determine how design principles were applied. Results Though the sample consisted of PEMs designed and developed to influence care, no single PEM scored well across all categories. Some PEMs failed to differentiate major recommendations and did not present them in a stepwise fashion. Most used clear and easy to read text, but highlighting was often inappropriate. Some algorithms lacked logic and consistency. Images were poorly designed and used, which may distract and confuse the reader. Discussion Design principles are not consistently applied in the development of PEMs and improvements are needed to images, presentation of recommendations, and usability of algorithms. Improvements to the design of PEMs may influence their uptake by combating information overload and increasing their perceived ease of use and perceived usefulness. Implications for Guideline Developers/Users Those who create guidelines and other PEMs consider some design principles, but do not implement them consistently. Our checklist can assist guideline developers in employing a range of design principles.

063 Enhancing the Uptake of Clinical Practice Guidelines: The Development of a Guideline Implementability Tool (Guide-It)

Background Guidelines have the potential to facilitate implementation of evidence into practice but this has not been consistently achieved. We developed a guideline implementability tool (GUIDE-IT), which can assess the implementability of guideline recommendations. Objective To determine if GUIDE-IT can improve the Language and Format of guideline recommendations. Methods Using a mixed-methods approach to develop GUIDE-IT, we conducted 1) a Realist Review of guideline factors influencing uptake, and used its results to build a conceptual model of guideline implementability; 2) qualitative interviews with 20 family physicians to determine factors influencing guideline uptake and to obtain input on tool design; 3) created a prototype and conducted validity assessments with experts in guideline development and human factors. GUIDE-IT was then pilot tested with the Canadian Diabetes/Paediatric Associations (CDA, CPS) to determine its potential for assessing the implementability of guideline recommendations. Results Pilot testing with CDA and CPS developers showed that factors across 4 sub-domains of Language (clarity, simplicity, specificity, and actionability) and 3 sub-domains of Format (presentation, components, and multiple versions) were applicable for modifying recommendations. GUIDE-IT was feasible to use by guideline developers to identify implementability problems and to improve recommendations. Discussion GUIDE-IT is based on a robust evidentiary base with the potential to improve guidelines. Next steps include evaluating GUIDE-IT in a controlled trial to determine its impact on end-user clinical decision making. Implications for Guideline Developers/Users GUIDE-IT has potential to be a practical tool for developers to improve the language and format of guideline recommendations.