Clinical practice guidelines were adapted and implemented meeting country-specific requirements--the example of Kazakhstan

GRADE guidance 39: using GRADE-ADOLOPMENT to adopt, adapt or create contextualized recommendations from source guidelines and evidence syntheses

BACKGROUND AND OBJECTIVE

The Grading of Recommendations, Assessment, Development and Evaluations (GRADE)-ADOLOPMENT methodology has been widely used to adopt, adapt, or de novo develop recommendations from existing or new guideline and evidence synthesis efforts. The objective of this guidance is to refine the operationalization for applying GRADE-ADOLOPMENT.

METHODS

Through iterative discussions, online meetings, and email communications, the GRADE-ADOLOPMENT project group drafted the updated guidance. We then conducted a review of handbooks of guideline-producing organizations, and a scoping review of published and planned adolopment guideline projects. The lead authors refined the existing approach based on the scoping review findings and feedback from members of the GRADE working group. We presented the revised approach to the group in November 2022 (approximately 115 people), in May 2023 (approximately 100 people), and twice in September 2023 (approximately 60 and 90 people) for approval.

RESULTS

This GRADE guidance shows how to effectively and efficiently contextualize recommendations using the GRADE-ADOLOPMENT approach by doing the following: (1) showcasing alternative pathways for starting an adolopment effort; (2) elaborating on the different essential steps of this approach, such as building on existing evidence-to-decision (EtDs), when available or developing new EtDs, if necessary; and (3) providing examples from adolopment case studies to facilitate the application of the approach. We demonstrate how to use contextual evidence to make judgments about EtD criteria, and highlight the importance of making the resulting EtDs available to facilitate adolopment efforts by others.

CONCLUSION

This updated GRADE guidance further operationalizes the application of GRADE-ADOLOPMENT based on over 6 years of experience. It serves to support uptake and application by end users interested in contextualizing recommendations to a local setting or specific reality in a short period of time or with limited resources.

Comparison of the methodological quality and transparency of Brazilian practice guidelines

This study aims to compare the differences between clinical practice guidelines (CPGs) of the Ministry of Health (MoH) and those of other Brazilian health institutions. A systematic review of Brazilian CPGs was carried out. CPGs with recommendations for the pharmacological treatment of non-communicable disease (NCDs) were included. CPG methodological quality and transparency was independently assessed by 2 reviewers using the AGREE II. CPGs were rated as high, moderate, and low quality (ranging from A to C). Twenty-six CPGs were assessed for quality. MoH CPGs were published more recently, and were of better quality than the others: 6/6 (100%) were rated as Moderate-A. Although CPGs presented a wide range of methodological quality and transparency, MoH CPGs presented better consistency in the preparation method. To avoid confusion and to improve the quality of care within finite resources in Brazil, and to avoid potential bias, conflicts of interest, national CPGs used within SUS should be developed by Conitec with partners who have no conflict of interest.

Clinical practice guidelines for surgical antimicrobial prophylaxis: Qualitative appraisals and synthesis of recommendations

RATIONALE, GOALS, AND OBJECTIVES

Clinical practice guidelines (CPGs) for preoperative care have been developed for surgical antimicrobial prophylaxis (SAP). The objective of this study was to synthetize recommendations for SAP based on best-evaluated CPGs.

METHODS

A systematic literature search for documents related to SAP, published between January 2011 and December 2016, was conducted on MEDLINE (PubMed), EMBASE, and specific CPG websites. Three reviewers independently assessed the rigour of development and editorial independence of CPGs based on domains 3 and 6 of the Appraisal of Guidelines for Research & Evaluation II (AGREE II) instrument. CPGs with domain 3 scores of 50% and greater were selected for synthesis of recommendations. Two reviewers independently extracted CPG recommendations from among these documents. A third reviewer performed the synthesis of recommendations.

RESULTS

The search retrieved 363 documents, of which 29 CPGs were appraised using AGREE II. Only eight (28%) scored 50% and greater in domain 3. Most CPGs addressed topics related to preoperative care, including SAP. No conflicting recommendations were found, and most recommendations were based on clinical practice. The only recommendation for which there was a difference among CPGs was with respect to the time to initiate the administration of antibiotics (1 hour before or close to the time of the surgical incision). Four CPGs provide recommendations that demonstrate concern about inadequate SAP prolongation.

CONCLUSION

Several CPGs for SAP were developed without the desired methodological rigour or transparency. Synthesis of recommendations for best-evaluated CPGs provides a broad approach owing to the complementarity of the recommendations.

An innovative method for clinical practice guideline contextualisation for chronic musculoskeletal pain in the South African context

BACKGROUND

Clinical guidelines produced in developed nations may not be appropriate in resource-constrained environments, due to differences in cultural, societal, economic and policy contexts. The purpose of this article is to describe an innovative and resource-efficient method to develop a clinical practice guideline (CPG), using the CPG contextualisation approach.

METHODS

The four phased contextualisation framework was applied to produce a contextualised, multidisciplinary CPG for the primary health care of adults with chronic musculoskeletal pain (CMSP) in the South African context. The four phases were: a contextual analysis, evidence synthesis, contextual integration and external evaluation. Qualitative methodology was used to investigate context factors influencing health care in this environment. A systematic review was conducted to identify current, high-quality CPGs on the topic, and to synthesise a core set of clinical recommendations from the CPGs. Consensus methods were used to integrate context information with recommendations. A multidisciplinary panel of local experts authenticated and contextualised recommendations. The resultant CPG was externally reviewed using a survey.

RESULTS

The results from the contextual analysis phase indicated a wide range of contextual factors that could influence the applicability and implementability of the recommendations, including: the personal characteristics of the patient and clinician, social and environmental circumstances, healthcare interventions available, and healthcare system factors. During phase two, six existent high quality CPGs were identified and a core set of multidisciplinary recommendations were sourced from them. The contextual integration phase produced the validated recommendations, accompanied by its underpinning body of evidence and context specific information. The outcome of phase four (external review) was that the recommendations were confirmed as relevant for the intended setting.

CONCLUSION

CPG contextualisation was found to be a practical approach to develop a contextualised multidisciplinary CPG for the primary health care of adults with CMSP in a South African setting. The contextualisation approach enhanced the integration of multiple stakeholder perspectives and highlighted the importance of considering clinical, social and economic complexities during CPG development. Attention to contextual information is advocated to enhance the uptake of CPG recommendations, particularly in resource constrained settings.

TRIAL REGISTRATION

Health Research Ethics Committee of Stellenbosch University, South Africa (S14/01/018); the review protocol was registered on PROSPERO (registration number CRD42015022098 ).

Assessment of the methodological quality of local clinical practice guidelines on the identification and management of gestational diabetes

OBJECTIVE

Gestational diabetes is the most common metabolic disorder of pregnancy, and it is important that well-written clinical practice guidelines (CPGs) are used to optimise healthcare delivery and improve patient outcomes. The aim of the study was to assess the methodological quality of hospital-based CPGs on the identification and management of gestational diabetes.

DESIGN

We conducted an assessment of local clinical guidelines in English for gestational diabetes using the Appraisal of Guidelines for Research and Evaluation (AGREE II) to assess and validate methodological quality.

DATA SOURCES AND ELIGIBILITY CRITERIA

We sought a representative selection of local CPGs accessible by the internet. Criteria for inclusion were (1) identified as a guideline, (2) written in English, (3) produced by or for the hospital in a Western country, (4) included diagnostic criteria and recommendations concerning gestational diabetes, (5) grounded on evidence-based medicine and (6) accessible over the internet. No more than two CPGs were selected from any single country.

RESULTS

Of the 56 CPGs identified, 7 were evaluated in detail by five reviewers using the standard AGREE II instrument. Interrater variance was calculated, with strong agreement observed for those protocols considered by reviewers as the highest and lowest scoring based on the instrument. CPG results for each of the six AGREE II domains are presented categorically using a 5-point Likert scale. Only one CPG scored above average in five or more of the domains. Overall scores ranged from 91.6 (the strongest) to 50 (the weakest). Significant variation existed in the methodological quality of CPGs, even though they followed the guideline of an advising body. Specifically, appropriate identification of the evidence relied on to inform clinical decision making in CPGs was poor, as was evidence of user involvement in the development of the guideline, resource implications, documentation of competing interests of the guideline development group and evidence of external review.

CONCLUSIONS

The limitations described are important considerations for updating current and new CPGs.

Quality and utilization of the Finnish clinical practice guideline in schizophrenia: evaluation using AGREE II and the vignette approach

PURPOSE

This study aims to evaluate the quality of the Finnish clinical practice guideline related to schizophrenia care and how it can be utilized in psychiatric services.

PARTICIPANTS AND METHODS

The data were collected from one psychiatric ward and seven psychiatric outpatient units situated in two cities in Southern Finland. A total of 49 professionals working in these sites participated in this study. A descriptive study design was adopted. The Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument with six domains including 23 items was used to assess the quality of the guideline, whereas a vignette was implemented to describe how staff would use the guideline in hypothetical cases in daily practice. The analysis of AGREE II was based on rating each of the 23 items on a seven-point scale and calculating a quality score for the six domains. To describe the utilization of the guideline, eight key recommendations of the guideline were deductively rated out of the respondents' answers.

RESULTS

The results showed that the "scope and purpose" of the guideline were well described, but "applicability" was insufficient. The overall quality of the guideline was high (73%). Almost one fifth of the respondents were in agreement with key recommendations.

CONCLUSION

The overall quality of Guideline for Schizophrenia was good, but its "applicability" and utilization should be improved.

Using a Modified ADAPTE Process to Enable Effective Implementation of Electrical Stimulation Therapy for Treating Pressure Ulcers in Persons With Spinal Cord Injury

Objectives:

To apply a modified ADAPTE process to adapt best practices to a local context for successful implementation of electrical stimulation therapy (EST) for treating pressure injuries in persons with spinal cord injury (SCI).

Participants:

An expert team of health care professionals and a consumer participated in a 2-day workshop to assist in the development of the locally adapted EST document in Southwest Ontario, Canada.

Results:

A process map illustrating the flow of activities to initiate EST for treating pressure injuries in persons with SCI based on the challenges and opportunities existing within this region was created. The team also developed a summary of roles and responsibilities delineating tasks specific to providing EST and identified a set of challenges likely to be encountered.

Conclusions:

The modified ADAPTE process provided a clear and flexible structure to adaptation when used for implementation planning. This article shares some challenges associated with using this process for local adaptation and shares strategies of improvement for future studies aimed at adapting a practice to their local environment.