Carmen Moga

Managing low back pain in the primary care setting: The know-do gap

OBJECTIVE To ascertain knowledge gaps in the diagnosis and treatment of acute and chronic low back pain (LBP) in the primary care setting to prepare a scoping survey for identifying knowledge gaps in LBP management among Albertas primary care practitioners, and to identify potential barriers to implementing a multidisciplinary LBP guideline. METHODS English language studies, published from 1996 to 2008, comparing the clinical practice patterns of primary care practitioners with guideline recommendations were identified by systematically searching literature databases, the websites of various health technology assessment agencies and libraries, and the Internet. Data were synthesized qualitatively. RESULTS The literature search identified 14 relevant studies. Knowledge gaps were reported among various primary care practitioner groups in the assessment of red flags, use of diagnostic imaging, provision of advice regarding sick leave and continuing activity, administration of some medications (muscle relaxants, oral steroids and opioids) and recommendation of particular treatments (acupuncture, physiotherapy, spinal manipulation, traction, ultrasound, transcutaneous electrical nerve stimulation and spinal mobilization). CONCLUSIONS A know-do gap clearly exists among primary care practitioners with respect to the diagnosis and treatment of LBP. The information on know-do gaps will be used to construct a survey tool for unearthing the local knowledge gaps extant among Albertas primary care practitioners, and to develop a dissemination strategy for a locally produced multidisciplinary LBP guideline, with the aim of ensuring that the know-do gaps inherent within each primary practice discipline are specifically targeted.

Creating a multidisciplinary low back pain guideline: anatomy of a guideline adaptation process.

RATIONALE, AIMS AND OBJECTIVES A collaborative, multidisciplinary guideline adaptation process was developed to construct a single overarching, evidence-based clinical practice guideline (CPG) for all primary care practitioners responsible for the management of low back pain (LBP) to curb the use of ineffective treatments and improve patient outcomes. METHODS The adaptation strategy, which involved multiple committees and partnerships, leveraged existing knowledge transfer connections to recruit guideline development group (GDG) members and ensure that all stakeholders had a voice in the guideline development process. Videoconferencing was used to coordinate the large, geographically dispersed GDG. Information services and health technology assessment experts were used throughout the process to lighten the GDGs workload. RESULTS The GDG reviewed seven seed guidelines and drafted an Alberta-specific guideline during 10 half-day meetings over a 12-month period. The use of ad hoc subcommittees to resolve uncertainties or disagreements regarding evidence interpretation expedited the process. Challenges were encountered in dealing with subjectivity, guideline appraisal tools, evidence source limitations and inconsistencies, and the lack of sophisticated evidence analysis inherent in guideline adaptation. Strategies for overcoming these difficulties are discussed. CONCLUSION Guideline adaptation is useful when resources are limited and good-quality seed CPGs exist. The Ambassador Program successfully utilized existing stakeholder interest to create an overarching guideline that aligned guidance for LBP management across multiple primary care disciplines. Unforeseen challenges in guideline adaptation can be overcome with credible seed guidelines, a consistently applied and transparent methodology, and clear documentation of the subjective contextualization process. Multidisciplinary stakeholder input and an open, trusting relationship among all contributors will ensure that the end product is clinically meaningful.

Making the AGREE tool more user‐friendly: the feasibility of a user guide based on Boolean operators

Rationale, aims and objectives The Appraisal of Guidelines Research and Evaluation (AGREE) instrument is a generic tool for assessing guideline quality. This feasibility study aimed to reduce the ambiguity and subjectivity associated with AGREE item scoring, and to augment the tools capacity to differentiate between good- and poor-quality guidelines. Methods A literature review was conducted to ascertain what AGREE instrument adjustments had been reported to date. The AGREE User Guide was then modified by: 1 constructing a detailed set of instructions, or dictionary, using Boolean operators, and 2 overlaying seven criteria to categorize guideline quality. The feasibility of the Boolean-based dictionary was tested by three appraisers using three randomly selected guidelines on low back pain management. The dictionary was then revised and re-tested. Results Of the 52 published studies identified, 14% had modified the instrument by adding or deleting items and 35% had adopted strategies, such as using a consensus approach, to overcome inconsistencies and ensure identical item scoring among appraisers. For the feasibility test, Pearson correlation coefficients ranged from 0.27 to 0.81. Revision and re-testing of the dictionary increased the level of agreement (range 0.41 to 0.94). Application of the revised dictionary not only decreased the variability of the domain scores, but also reduced the tools reliability among inexperienced appraisers. Conclusion Appraisers found the Boolean-based AGREE User Guide easier to use than the original, which improved their confidence in the tool. Good reliability was achieved in the feasibility test, but the reliability and validity of some of the changes will require further evaluation.

Mentoring a developing health technology assessment initiative in Romania : An example for countries with limited experience of assessing health technology

OBJECTIVES The aim of this study was to assist and facilitate introduction and development of a health technology assessment (HTA) program in Romania. METHODS Mentoring of an initiative group in Romania was provided by an HTA program in Canada. Mentoring activities included provision of HTA materials, participation in local seminars, facilitating contact with HTA and funding organizations, and in-house training of a professional from Romania. RESULTS Since 1998, when the relationship was initiated, the Romanian group has been successful in developing an understanding of HTA and awareness of its utility among various decision-makers in the health system. Currently, although the need for HTA in Romania exists and interest in developing this activity has been officially expressed, HTA is still early in its development phase. The mentoring support helped to identify and define the need for HTA in Romania. Continuation of the existing relationship can be expected to strengthen the expertise in this country. However, while mentoring has been a valuable activity, it is not, by itself, sufficient to ensure development of an HTA program in Romania. The actions and decisions that could lead to implementing HTA in Romania depend on the local context. CONCLUSIONS Mentoring services assisted the initiative group in promoting HTA in Romania. The implementation of HTA in Romania has not happened yet, and efforts need to continue to sustain the existing momentum. However, success in implementing an HTA program will depend on essential factors such as local political, economical, and educational support for this initiative and others like it.

Adapting low back pain guidelines within a multidisciplinary context: a process evaluation

RATIONALE, AIMS AND OBJECTIVES The Alberta Ambassador Program (AAP) adapted seven clinical practice guidelines on low back pain (LBP) into a single guideline spanning the continuum of care from prevention and diagnosis through to treatment. The Ambassador adaptation process was evaluated to 1 Identify the major challenges encountered and successful strategies utilized; 2 Assess strengths and weaknesses by benchmarking it with the ADAPTE framework; and 3 Identify opportunities for improvement. METHOD External consultants reviewed the Ambassador and ADAPTE materials and conducted semi-structured telephone interviews with 29 participants from the AAP committees. All participants were asked about the major challenges encountered and potential areas for improvement. RESULTS The response rate was 83% (29/35). There was strong consensus that the Ambassador guideline adaptation process was sound and rigorous all respondents indicated willingness to participate in further iterations of the Program. Key elements of success were identified. The main steps and sequence of the process were closely aligned with the ADAPTE framework, although the AAP incorporated additional enhancements which augmented the process. The main divergences between the two frameworks centred on the organizational structure and the methods used to overcome methodological difficulties. CONCLUSION The AAP successfully utilized existing stakeholder interest to create an overarching guideline for managing LBP across multiple primary care disciplines. The study highlighted the strengths and weaknesses of the Program, and identified practical strategies for improvement. Evaluating guideline adaptation processes is pivotal to ensuring that they continue to be an efficient, rigorous and practicable option for producing contextualized, clinically relevant guidelines.

VP190 A Review Of Best Practices In Five Mental Disorders In Youth

In order to support service planning of the youth program of the East of Montreal Health and Social Services Board, and potentially of the other twenty-five programs across the Quebec province, our hospital-based Health Technology Assessment (HTA) unit was asked to bring evidence of the effective interventions for five most commonmental disorders in children and young populations, namely anxio-depressive disorders, attention deficit and hyperactivity disorder, oppositional and conduct disorders, substance abuse disorders, and suicide attempts.

S30– Adapting the ADAPTE Framework

ment. 3. Describe processes for developing and revising guidelines based on current evidence and for gaining consensus by developers. 4. Describe key challenges facing the guideline developer. METHODS: In this session, we will describe the methods the Institute for Clinical Systems Improvement utilizes to develop and revise guidelines. We will discuss how we garner peer review of the documents prior to revision, the review of evidence, the group process utilized to review the document and the peer review completed prior to publication. During this session we will also present methods to reduce bias and obtain consensus. We will review the process used to develop aims and measures for improvement that organizations use in their quality improvement activities. In addition we will discuss some of the current and future challenges of developing and disseminating guidelines to practicing providers. RESULTS: None provided. DISCUSSION (CONCLUSION): None provided. TARGET AUDIENCE(S): 1. Guideline developer 2. Guideline implementer 3. Developer of guideline-based products 4. Quality improvement manager/facilitator 5. Health insurance payers and purchasers 6. Medical providers and executives 7. Allied health professionals 8. Nurses

S41– Just finished developing a guideline; how did we do? A process evaluation

Results: Even though the Alberta healthcare system was undergoing major changes we had a response rate of 86% (30/35). There was strong consensus among the stakeholders interviewed that the process used to develop the CPG for low back pain was a sound and rigorous research process. This was primarily due to the following: strong project leadership; multi-disciplinary approach; Province-wide representation on both the Advisory Committee and Guideline Development Group (GDG); relevance to primary healthcare; substantial support provided by the Project Team; commitment among all participants to a transparent process; and quality evidence-informed product. The process was found to be closely aligned with the ADAPTE framework and included additional enhancements to the quality appraisal tool for the CPGs; use of the GLIA tool to develop the recommendations and patient input.