Elizabeth Estey

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.

Methodologies to evaluate the effectiveness of knowledge translation interventions: a primer for researchers and health care managers

OBJECTIVE The evidence base for interventions to change clinical practice is modest but growing. Given the large variation in impact and costs, this review aims to highlight the importance of evaluating knowledge translation (KT) interventions by managers and researchers. STUDY DESIGN AND SETTING To meet its objectives, this review article discusses how the need for local or generalizable information and the resources available guide the evaluations. Furthermore, we discuss how study designs can focus on establishing internal validity or applicability and how the choice of focus affects the study design. RESULTS This review argues that managers should routinely incorporate simple evaluation designs into program implementation to assess and increase the impact of their services, whereas researchers should focus on creating cumulative knowledge through rigorous designs and rich descriptions of context and implementation to explore reasons for success and failure. CONCLUSION We suggest that the combined effort of managers and researchers will provide a richer knowledge base to move the field of KT forward and increase the use of evidence-based implementation strategies to improve the quality of health care provided.

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.

Better guidelines for better care: enhancing the implementability of clinical practice guidelines

The potential of clinical practice guidelines to promote evidence-based care has not been consistently realized. This article outlines how modifying guidelines, and specifically their implementability (the perceived characteristics that influence their use in practice), could be an inexpensive way to improve care. The article uses a planned action model, Graham’s knowledge-to-action framework, to illustrate how this framework can be applied in the context of an ongoing research initiative. It describes each step from knowledge synthesis, to barrier analysis, intervention development and evaluation of a guideline implementability tool that could facilitate uptake of guidelines in clinical practice. This tool targets guideline developers, so that better guidelines may result in better care.

Canadian Thoracic Society: Presenting a new process for clinical practice guideline production

A key mandate of the Canadian Thoracic Society (CTS) is to promote evidence-based respiratory care through clinical practice guidelines (CPGs). To improve the quality and validity of the production, dissemination and implementation of its CPGs, the CTS has revised its guideline process and has created the Canadian Respiratory Guidelines Committee to oversee this process. The present document outlines the basic methodological tools and principles of the new CTS guideline production process. Important features include standard methods for choosing and formulating optimal questions and for finding, appraising, and summarizing the evidence; use of the Grading of Recommendations Assessment, Development and Evaluation system for rating the quality of evidence and strength of recommendations; use of the Appraisal of Guidelines for Research and Evaluation instrument for quality control during and after guideline development and for appraisal of other guidelines; use of the ADAPTE process for adaptation of existing guidelines to the local context; and use of the GuideLine Implementability Appraisal tool to augment implementability of guidelines. The CTS has also committed to develop guidelines in new areas, an annual guideline review cycle, and a new formal process for dissemination and implementation. Ultimately, it is anticipated that these changes will have a significant impact on the quality of care and clinical outcomes of individuals suffering from respiratory diseases across Canada.

Providers’ perceptions of barriers to the management of type 2 diabetes in remote Aboriginal settings

Objectives. To examine providers’ perspectives of the barriers to providing diabetes care in remote First Nation communities in the Sioux Lookout Zone (SLZ) of Northwestern Ontario, Canada. Study design. A qualitative study involving key informant interviews and focus groups was conducted with health care providers working in remote First Nation communities in SLZ. Methods. Twenty-four nurses, doctors, diabetes educators and community health representatives (CHRs) participated in qualitative interviews and focus groups. Data collected from the interviews and focus groups was coded and thematically analysed using NVIVO software. Results. Barriers to diabetes care were grouped into patient, clinic and system factors. Providers’ perceptions of patient factors were divided between those advocating for a patient–provider partnership and those advocating for greater patient responsibility. Clinic-related barriers such as short staffing, staff turnover and system fragmentation were discussed, but were often overshadowed by a focus on patient factors and a general sense of frustration among providers. Cultural awareness and issues with clinic management were not mentioned, though they are both within the providers’ control. Conclusions. This study characterizes a range of barriers to diabetes care and shows that patient-related factors are of primary concern for many providers. We conclude that patient-focused interventions and cultural competence training may help improve patient–provider partnerships. Funding and supporting quality improvement initiatives and clinic reorganization may increase the providers’ knowledge of the potential for clinical strategies to improve patient outcomes and focus attention on those factors that providers can change. Future research into the factors driving quality of care and strategies that can improve care in Aboriginal communities should be a high priority in addressing the rising burden of diabetes and related complications.

S8– Adopting a realist review approach to conceptualizing the relationship between the perceived characteristics of clinical practice guidelines and their uptake

appraisals. Final amendments to each tool were then made. RESULTS: Both percentage agreement and inter-rater reliability between reviewers for individual GATE items in the first round were variable for all five study designs. Agreement on summary scores was generally rated poor for all categories, mostly due to individual interpretations of which checklist items were important in contributing to the final assessment. Amendments to checklists included both amendments to individual checklist questions and/or the accompanying explanatory notes. Following discussion between reviewers and amendment to checklist items, crude agreement and PABAK scores in the second round for all five study designs showed improvement, including summary scores in most cases. DISCUSSION (CONCLUSION): The amended GATE checklists demonstrate improved inter-rater reliability for appraising studies. This study shows how critical appraisal checklists used in guideline development could be systematically improved by undertaking inter-rater reliability assessments to improve the reliability of critical appraisal processes during the production of an evidence-based guideline. TARGET AUDIENCE(S): 1. Clinical researcher 2. Evidence synthesizer, developer of systematic reviews or meta-analyses 3. Guideline developer 4. Quality improvement manager/facilitator