Christa Harstall

Systematic review: faecal transplantation for the treatment of Clostridium difficile-associated disease

Management of recurrent Clostridium difficile‐associated disease (CDAD), particularly in elderly patients, remains clinically challenging. Faecal transplantation (FT) may restore normal microbiota and break the cycle of recurrent CDAD.

THE USE AND IMPACT OF RAPID HEALTH TECHNOLOGY ASSESSMENTS

OBJECTIVES To consider the impact of rapid health technology assessments undertaken as part of a program in a provincial healthcare system in response to urgent requests for advice. METHODS Review of the development and preparation of 20 rapid assessment reports, communication with decision makers within the healthcare system, and appraisal of data subsequent to preparation of the reports. RESULTS Fourteen of the assessments were judged to have had an influence on policy and other decisions, as judged by responses from those who had requested advice. Another four were considered to have provided guidance, while having less immediate influence on decisions, and two others had no apparent impact. Quality of the assessments was considered acceptable, on the basis of literature that subsequently became available and from comments received. CONCLUSIONS These brief reports are considered to be a useful component of a health technology assessment program. However, they should be regarded as provisional appraisals and followed up with more detailed evaluation where possible.

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.

Tackling ethical issues in health technology assessment: A proposed framework

OBJECTIVES Values are intrinsic to the use of health technology assessments (HTAs) in health policy, but neglecting value assumptions in HTA makes their results appear more robust or normatively neutral than may be the case. Results of a 2003 survey by the International Network of Agencies for Health Technology Assessment (INAHTA) revealed the existence of disparate methods for making values and ethical issues explicit when conducting HTA. METHODS An Ethics Working Group, with representation from sixteen agencies, was established to develop a framework for addressing ethical issues in HTA. Using an iterative approach, with email exchanges and face-to-face workshops, a report on Handling Ethical Issues was produced. RESULTS This study describes the development process and the agreed upon framework for reflexive ethical analysis that aims to uncover and explore the ethical implications of technologies through an integrated, context-sensitive approach and situates the proposed framework within previous work in the development of ethics analysis in HTA. CONCLUSIONS It is important that methodological approaches to address ethical reflection in HTA be integrative and context sensitive. The question-based approach described and recommended here is meant to elicit this type of reflection in a way that can be used by HTA agencies. The questions proposed are considered only as a starting point for handling ethics issues, but their use would represent a significant improvement over much of the existing practice.

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.

Posteroventral pallidotomy for Parkinson's Disease: assessment and policy on a technology in transition

Posteroventral pallidotomy (PVP) is a neurosurgical technique used in the management of persons with Parkinsons Disease whose symptoms can no longer be controlled by medical treatment. There is pressure on policy areas to provide support for this intervention. An assessment of the status of the technology concluded that the available evidence of efficacy of PVP was only fair to poor, and that the technology was continuing to evolve. Nevertheless, it was suggested that support for PVP, linked to collection of outcomes data, would be justified, taking account of the morbidity and poor quality of life for this type of patient, and limitations of alternative methods of management. This case study provides an example of the dilemmas facing policy areas in dealing with evolving technology, with limited available evidence and with the prospect of further management options becoming available.

More than mingling: The potential of networks in facilitating knowledge translation in health care

Health care practitioners and managers often report difficulty keeping up with new health care research and may lack the skills to use research evidence in their workplace, and researchers often report constrained time and opportunity to exchange ideas with those who can benefit from their work. Although studies suggest micro ~one-on-one! and meso ~organizational0group! engagement are effective research translation strategies for addressing these barriers, less attention has been given to the role of macrolevel structures, such as networks, in facilitating micro and meso interchange. As a structure that connects many individuals, organizations, and groups, networks can act as key information-delivery and capacity-building arrangements, promoting connections and interpersonal development between health care practitioners, administrators, and researchers who may not otherwise interact. Why We Undertook This Initiative