The development, implementation and evaluation of clinical practice guidelines in Gulf Cooperation Council (GCC) countries: a systematic review of literature

Clinical Practice Guidelines in an Era of Accountability, Saudi Arabia: A Call for Action

INTRODUCTION

Clinical Practice Guidelines (CPGs) development and implementation in the Kingdom of Saudi Arabia are suboptimal. The Kingdom's Vision 2030 envisages a transformational change to achieve an effective, integrated, value-based ecosystem focused on patient health.

OBJECTIVES

This study aimed to develop a CPG appraisal tool that will support the realization of the Kingdom's Vision 2030 through the development of high-quality and highly implementable CPGs. To maximize its impact, all vital healthcare paradigms, such as systems thinking, value-based healthcare, and information technology, will robustly be incorporated in the tool.

METHODS

The Saudi Health Council through its National Center of Evidence-Based Medicine (NCEBM) embarked on a program to develop this appraisal tool. A taskforce of experts was selected based on their experience in evidence-based practice and training. The task force, through a methodology of extensive literature review, deliberation, outside experts' feedback, and Delphi and consensus voting, developed a prototype appraisal tool that was named the Holistic Appraisal Tool for CPGs (HAT-CPG).

RESULTS

The HAT-CPG was developed comprising three sections: an initial basic information section, an internal validity section, and an external validity section with a total of 13 section items and 73 reporting elements.

CONCLUSION

It is envisaged that the Holistic Appraisal Tool will support CPG developers and users in Saudi Arabia in realizing the objectives for which it was developed.

Application of MAT Methodology in the Evaluation of Prescribing Adherence to Clinical Practice Guidelines for Secondary Prevention of Coronary Heart Disease in Post-Acute Coronary Syndrome Patients in Kuwait

Quantification of prescribers’ adherence to evidence-based guidelines can be used as an outcome measure to assess the impact of services on the quality of medication use. Additionally, it can help in reducing inappropriate interventions and ensure that high-quality care is provided to patients. This study aimed to evaluate prescribing practices for secondary prevention of coronary heart disease (CHD) in post-acute coronary syndromes (ST-elevation myocardial infarction [STEMI] or non-ST elevation acute coronary syndrome [NSTEACS]) patients using two medication assessment tools (MATs) at secondary and tertiary health-care settings in Kuwait. Both MATs were developed and validated based on the relevant guidelines issued by the European Society of Cardiology and the American College of Cardiology/American Heart Association. A quantitative cross-sectional multicenter study was conducted on 460 patients’ medical records collected randomly from six health-care facilities in Kuwait. Application of MAT_STEMI on 232 patients’ medication records (with 85.9% applicability) resulted in intermediate overall adherence (69.8%; 95% CI: 67.6–72.0). Application of MAT_NSTEACS on 228 patients’ medication records (with applicability 83.2%) resulted in intermediate overall adherence (73.3%; 95% CI: 70.5–76.0). There was no significant difference between the percentages of overall adherence among patients managed post-NSTEACS compared to those managed post-STEMI (p = 0.05). Multivariable logistic regression analysis revealed that the overall adherence to the MAT_STEMI criteria was significantly higher among the specialized cardiac centers than among the general hospitals (OR: 1.6; 95% CI: 1.1–2.3; p = 0.02). The overall adherence to the MAT_NSTEACS criteria was found to be significantly lower among non-Kuwaitis than among Kuwaitis (OR: 0.6; 95% CI: 0.5–0.9; p = 0.01) and patients with a serum LDL ≥1.8 mmol/L than those with a serum LDL-C < 1.8 mmol/L (OR: 0.5; 95% CI: 0.4–0.7; p < 0.001). The present findings revealed that both MATs were useful tools in identifying the standard of clinical performances and highlighting areas for improvement regarding secondary prevention of CHD in post-acute coronary syndrome patients.

Barriers and facilitators to conducting economic evaluation studies of Gulf Cooperation Council (GCC) countries: a survey of researchers

Background

The number of published economic evaluations of Gulf Cooperation Council (GCC) countries is notably scarce. Limited local evidence could have a major impact on the implementation of economic evaluation recommendations in the decision-making process in GCC countries. Little is known about the factors affecting researchers who seek to conduct economic evaluations. Therefore, we aimed to assess researcher barriers and facilitators in conducting such studies of GCC countries.

Methods

A cross-sectional survey of health economic researchers working in GCC countries was conducted online between January and February 2020. The survey instrument collected researchers’ perceived barriers and facilitators and demographic information. For barriers, respondents rated their agreement on a 5-point Likert scale ranging from “strongly disagree” to “strongly agree”. For facilitators, respondents rated the importance of each facilitator on a six-point scale ranging from “extremely important” to “not very important”. Then, participants were asked to select the three most important barriers and facilitators from the lists. The data collected were examined using descriptive analysis.

Results

Fifty-one researchers completed the survey (37% response rate). The majority of participants (more than 80%) agreed that lack of quality of effectiveness data and restricted access to unit cost data are the main barriers to conducting economic research. Availability of relevant local data was reported as an important facilitator, followed by collaboration between health economic researchers, policy-makers and other stakeholders.

Conclusions

The results of this study provide an exploratory view of the issues faced by health economics researchers in GCC countries. Recommendations to GCC countries based on international experiences, such as to use real-world data in economic evaluation research, were provided.

Adapting evidence-based clinical practice guidelines for people with attention deficit hyperactivity disorder in Saudi Arabia: process and outputs of a national initiative

BACKGROUND

We recently adapted the published National Institute for Health and Care Excellence (NICE) Attention deficit hyperactivity disorder (ADHD) diagnosis and management guideline to the Saudi Arabian context. It has been postulated that adaptation of evidence-based clinical practice guidelines to the local healthcare context rather than de-novo development will improve their adoption and implementation without imposing a significant burden on resources. The objective of this paper is to describe the adaptation process methodology utilized for the generation of the first national guideline for management of people with ADHD in Saudi Arabia.

METHODS

We used the KSU-Modified-ADAPTE methodology for the guideline adaptation process. We describe the full process in detail including the three phases of set-up, adaptation, and finalization. The process was conducted by a multidisciplinary guideline adaptation group in addition to an external review for the clinical content and methodology.

RESULTS

The group adapted ten main categories of recommendations from one source CPG (NICE). The recommendations include: (i) service organisation and training, (ii) recognition, identification and referral, (iii) diagnosis, (iv) support, (v) managing ADHD, (vi) dietary advice, (vii) medication, (viii) maintenance and monitoring, (ix) adherence to treatment, and (x) review of medication and discontinuation. Several implementation tools were compiled and developed to enhance implementability including a clinical algorithm, quality measures, coding system, medication tables, translations, patient information, and online resources.

CONCLUSIONS

The finalized clinical practice guideline provides healthcare providers with applicable evidence-based guidance for the management of people with ADHD in Saudi Arabia. The project also demonstrated the effectiveness of KSU-Modified-ADAPTE, and emphasized the value of a collaborative clinical and methodological expert group for adaptation of national guidelines.

Barriers to and Facilitators of Adherence to Clinical Practice Guidelines in the Middle East and North Africa Region: A Systematic Review

The current review aims to investigate the barriers to and facilitators of the adherence to clinical practice guidelines (CPGs) in the Middle East and North Africa (MENA) region. English language studies published between January 2010 and May 2019 were searched on PubMed, Embase, and EBSCO. The barriers were categorized as clinician-related factors, such as lack of awareness of familiarity with the CPGs, and external factors, such as patients, guidelines, and environmental factors. The search identified 295 titles, out of which 15 were included. Environmental factors, specifically lack of time, resources, incentives, availability, and costs of treatment or diagnostic tests, training, and dissemination plans were the most commonly identified barriers. The familiarity with or awareness of healthcare professionals about the guideline, guideline characteristics, lack of agreement with the guidelines and preference in clinical judgment, physician self-efficacy, and motivation were reported to a lesser extent. Few studies reported on the compliance of facilitators with the guidelines including disseminating and advertising guideline materials, education and training on the guidelines, regulatory and financial incentives, and support from institutions. The review highlights that the studies on barriers to and facilitators of compliance with CPGs in the MENA region are limited in number and quality.

Primary open angle glaucoma management in a tertiary eye care center in Saudi Arabia: a best practice implementation pilot project

AIM

Primary open angle glaucoma (POAG) is a leading cause of permanent visual loss affecting significant numbers in Saudi Arabia. There is no cure for glaucoma but there is mounting evidence to guide ophthalmologists in diagnosing and managing this disease. The aim of this pilot project was to assess the compliance with evidence-based criteria and to implement an adapted clinical practice guideline (CPG) for the management of patients with POAG at a tertiary eye care center in Riyadh, Saudi Arabia that will lead to improving quality, consistency and optimizing patients' care.

METHODS

The project consisted of three phases using audit and feedback strategy. It has utilized the Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice audit and feedback tool. Eleven evidence-based audit criteria were developed. A baseline audit was then conducted. Barriers behind areas of noncompliance were identified and a number of strategies were implemented to overcome them. A follow-up postimplementation audit was then conducted.

RESULTS

Twenty electronic medical files were randomly selected for baseline audit. The results of the audit have identified a number of possible areas to improve in the diagnosis and management of POAG in compliance with the adapted CPG with compliance rate as low as 20% (4/20) in some criteria. Multifaceted interventions were implemented targeting mainly attitude and lack of knowledge and time and resource barriers. Significant improvement occurred in most criteria audited postimplementation.

CONCLUSION

The project demonstrates that audit and feedback is a feasible and effective tool to change glaucoma practice in a teaching hospital in Saudi Arabia. The success was due to multifaceted interventions including clear communication to promote awareness, an easily accessible CPG, and regular reminders to improve knowledge and change behavior. We propose our pilot implementation to be generalized to promote implementing evidence-based ophthalmology.

Progress and outcomes of health systems reform in the United Arab Emirates: a systematic review

BACKGROUND

The United Arab Emirates (UAE) government aspires to build a world class health system to improve the quality of healthcare and the health outcomes for its population. To achieve this it has implemented extensive health system reforms in the past 10 years. The nature, extent and success of these reforms has not recently been comprehensively reviewed. In this paper we review the progress and outcomes of health systems reform in the UAE.

METHODS

We searched relevant databases and other sources to identify published and unpublished studies and other data available between 01 January 2002 and 31 March 2016. Eligible studies were appraised and data were descriptively and narratively synthesized.

RESULTS

Seventeen studies were included covering the following themes: the UAE health system, population health, the burden of disease, healthcare financing, healthcare workforce and the impact of reforms. Few, if any, studies prospectively set out to define and measure outcomes. A central part of the reforms has been the introduction of mandatory private health insurance, the development of the private sector and the separation of planning and regulatory responsibilities from provider functions. The review confirmed the commitment of the UAE to build a world class health system but amongst researchers and commentators opinion is divided on whether the reforms have been successful although patient satisfaction with services appears high and there are some positive indications including increasing coverage of hospital accreditation. The UAE has a rapidly growing population with a unique age and sex distribution, there have been notable successes in improving child and maternal mortality and extending life expectancy but there are high levels of chronic diseases. The relevance of the reforms for public health and their impact on the determinants of chronic diseases have been questioned.

CONCLUSIONS

From the existing research literature it is not possible to conclude whether UAE health system reforms are working. We recommend that research should continue in this area but that research questions should be more clearly defined, focusing whenever possible on outcomes rather than processes.