Evidence-basing for quality improvement; bringing clinical practice guidelines closer to their promise of improving care practices

BACKGROUND

Clinical practice guidelines (CPGs) have become central to efforts to change clinical practice and improve the quality of health care. Despite growing attention for rigorous development methodologies, it remains unclear what contribution CPGs make to quality improvement.

AIM

This mixed methods study examines guideline quality in relation to the availability of certain types of evidence and reflects on the implications of CPGs' promise to improve the quality of care practices.

METHODS

The quality of 62 CPGs was assessed with the Appraisal of Guidelines, Research, and Evaluation (AGREE) instrument. Findings were discussed in 19 follow-up interviews to examine how different quality aspects were considered during development.

RESULTS

The AGREE assessment showed that while some quality criteria were met, CPGs have limited coverage of domains such as stakeholder involvement and applicability, which generally lack a 'strong' evidence base (e.g., randomized controlled trials [RCT]). Qualitative findings uncovered barriers that impede the consolidation of evidence-based guideline development and quality improvement including guideline scoping based on the patient-intervention-comparison-outcome (PICO) question format and a lack of clinical experts involved in evidence appraisal. Developers used workarounds to include quality considerations that lack a strong base of RCT evidence, which often ended up in separate documents or appendices.

CONCLUSION

Findings suggest that CPGs mostly fail to integrate different epistemologies needed to inform the quality improvement of clinical practice. To bring CPGs closer to their promise, guideline scoping should maintain a focus on the most pertinent quality issues that point developers toward the most fitting knowledge for the question at hand, stretching beyond the PICO format. To address questions that lack a strong evidence base, developers actually need to appeal to other sources of knowledge, such as quality improvement, expert opinion, and best practices. Further research is needed to develop methods for the robust inclusion of other types of knowledge.

Office Insertion of Tympanostomy Tubes and the Role of Automated Insertion Devices

OBJECTIVE

Insertion of tubes in an office setting and automated tube insertion devices were identified as high-priority quality improvement opportunities during the update process for the 2013 clinical practice guideline on tympanostomy tubes from the American Academy of Otolaryngology-Head and Neck Surgery. The guideline update group, however, decided to avoid any recommendations on these topics, based on limited research evidence, and instead selected a subset of group members to author this state of the art review, with the goal of facilitating informed decisions in clinical practice.

DATA SOURCES

PubMed through September 2021, Google search of device manufacturer websites, and SmartTots research website for articles on anesthesia neurotoxicity.

REVIEW METHODS

A state of the art review format emphasizing evidence from the past 5 years, with manual cross-checks of reference lists of identified articles for additional relevant studies.

CONCLUSIONS

The existing literature is too sparse to make recommendations about procedure setting and optimal technique or assess long-term outcomes. The role of automated devices is uncertain, given the increased equipment cost and limited information on characteristics of the proprietary preloaded tubes, including intubation duration and rates of otorrhea, obstruction, medialization, granulation tissue, and persistent perforation.

IMPLICATIONS FOR PRACTICE

Whether to undertake in-office tube insertion in awake children should be based on clinician experience, clinician ability to interact with and reassure caregivers, shared decisions with caregivers, and judgment regarding the level of cooperation (or lack thereof) to be expected from a given child. Clinicians should remain alert to new research and expect increasing queries from patients and families.

Dissemination and implementation of strategy adoption guidelines for persons with dementia at risk of getting lost

OBJECTIVES

To address risks associated with critical dementia-related wandering, three guidelines were developed for use by persons living with dementia, their care partners, and professional staff, to choose wander-management strategies. This evidence-based research incorporates knowledge mobilization approaches that directly involve the three types of stakeholders in using the guidelines in the real world. The purpose of this project was to evaluate the knowledge translation of three guidelines on wander-management strategies, and to further deploy these guidelines to organizations across Canada.

METHODS

Steering committees across Canada were established for consultation. Guidelines were then shared among these organizations via Google slides. Health professionals, caregivers, community organizations and persons living with dementia completed an online survey (via Google) or paper-based survey to provide feedback on the guidelines. The guidelines were then translated from English to French using a forward-translation method.

RESULTS

The guidelines were adopted across ten organizations in four Canadian provinces. Adoption included introduction and formal training to staff. It took 22 months from the development of the guidelines to the dissemination and launch of the guidelines to the organizations. Participants (n = 73) were very satisfied with the developed guidelines and agreed they were easy to navigate, easy to understand, and the information provided was useful.

CONCLUSIONS

A stakeholder-driven approach used for guideline development and dissemination were successful methods for minimizing the time for this work to become practice. This in addition to the use of online platforms can replace conventional methods which take longer and become quickly outdated.

American Academy of Otolaryngology-Head and Neck Surgery/Foundation Reg-ent Registry: Purpose, Properties, and Priorities

OBJECTIVE

(1) To describe the patient and membership cohort captured by the otolaryngology-based specialty-specific Reg-ent registry. (2) To outline the capabilities of the Reg-ent registry, including the process by which members can access evidence-based data to address knowledge gaps identified by the American Academy of Otolaryngology-Head and Neck Surgery/Foundation and ultimately define "quality" for our field of otolaryngology-head and neck surgery.

METHODS

Data analytics was performed on Reg-ent (2015-2020).

RESULTS

A total of 1629 participants from 239 practices were enrolled in Reg-ent, and 42 health care specialties were represented. Reg-ent encompassed 6,496,477 unique patients and 24,296,713 encounters/visits: the 45- to 64-year age group had the highest representation (n = 1,597,618, 28.1%); 3,867,835 (60.3%) patients identified as Caucasian; and "private" was the most common insurance (33%), followed by Blue Cross/Blue Shield (22%). Allergic rhinitis-unspecified and sensorineural hearing loss-bilateral were the top 2 diagnoses (9% each). Overall, 302 research gaps were identified from 17 clinical practice guidelines.

DISCUSSION

Reg-ent benefits are vast-from monitoring one's practice to defining otolaryngology-head and neck surgery quality, participating in advocacy, and conducting research. Reg-ent provides mechanisms for benchmarking, quality assessment, and performance measure development, with the objective of defining and guiding best practice in otolaryngology-head and neck surgery. To be successful, patient diversity must be achieved to include ethnicity and socioeconomic status. Increasing academic medical center membership will assist in achieving diversity so that the quality domain of equitable care is achieved.

IMPLICATIONS FOR PRACTICE

Reg-ent provides the first ever registry that is specific to otolaryngology-head and neck surgery and compliant with HIPAA (Health Insurance Portability and Accountability Act) to collect patient outcomes and define evidence-based quality care.

A Theoretical Framework and Competency-Based Approach to Training in Guideline Development

BACKGROUND

There is increasing requirement to develop guidelines using transparent, standardized, and rigorous methods. Consequently, a better understanding of the knowledge, skills, and expertise necessary for guideline development is needed. The aim of this manuscript is to describe a theoretical framework of knowledge and skills that are required for individuals to serve on a guideline panel in varying capacities.

METHODS

Based on an iterative process and review of published manuscripts focused on guideline development, we identified competencies, subcompetencies, and milestones.

RESULTS

Using a competency-based approach to training and the Dreyfus model of skill acquisition, we identified three core competencies: (1) facilitate the development of guideline structure and setup, (2) make judgments about the quality or certainty of the evidence, and (3) transform evidence to a recommendation. Level 1 focuses on recognizing and acknowledging the importance of a specific skill or behavior. Levels 2 and 3 require learners to demonstrate progressive acquisition of knowledge and application to specific behaviors. Level 4 represents the individual who has acquired the requisite knowledge and can function independently, while level 5 represents the mastery/aspirational level.

DISCUSSION

We propose a preliminary competency-based education framework that will (1) help standardize the qualifications needed for individuals to serve on guideline panels in varying capacities or (2) help with curricula development for teaching and training of guideline panel members. This framework can also help enable guideline-producing organizations to identify guideline methodologists with the relevant and appropriate level of knowledge and skills to lead guidelines. Validation of the framework and further refinement of the competencies and milestones will be required before widespread adoption.

Patient Safety/Quality Improvement Primer, Part I: What PS/QI Means to Your Otolaryngology Practice

Patient safety/quality improvement (PS/QI) is the cornerstone of 21st-century health care. Otolaryngology-Head and Neck Surgery is excited to provide a dedicated PS/QI primer. The overarching goal for this PS/QI series is to provide a comprehensive and practical resource that assists readers, authors, and peer reviewers in understanding PS/QI research, its unique methodology, and the associated reporting standards for trustworthy performance measures. The target audience includes resident and fellows, faculty from the private sector and academia, and allied health professionals. This inaugural primer reviews PS/QI background as it relates to otolaryngology practice. It explores the history, goals, and development of performance measurement. In addition, it highlights opportunities for integrating PS/QI into otolaryngology practice. Payers will drive patients to quality care based on outcomes. Otolaryngologists have a responsibility to embrace a culture of PS/QI. In doing so, we will define optimal, quality otolaryngology care through objective data and metrics.

Is GRADE the Right Choice for Clinical Practice Guidelines Developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation?

Clinical practice guidelines (CPGs), developed to inform clinicians, patients, and policy makers about what constitutes optimal clinical care, are one way of increasing implementation of evidence into clinical practice. Many factors must be considered by multidisciplinary guideline panels, including strength of available evidence, limitations of current knowledge, risks/benefits of interventions, patient values, and limited resources. Grading of Recommendations Assessment, Development and Evaluation (GRADE) is a framework for summarizing evidence that has been endorsed by many national and international organizations for developing CPGs. But is GRADE the right choice for CPGs developed by the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF)? In this commentary, we will introduce GRADE, discuss its strengths and limitations, and address the question of what potential benefits GRADE might offer beyond existing methodology used by the AAO-HNSF in developing CPGs.

In Their Own Words: Caregiver and Patient Perspectives on Stressors, Resources, and Recommendations in Craniofacial Microsomia Care

This study describes stressors, resources, and recommendations related to craniofacial microsomia (CFM) care from the perspective of caregivers of children with CFM and adults with CFM to inform improved quality of healthcare delivery. A mixed method design was used with fixed-response and open-ended questions from an online survey in English. The survey included demographics, CFM phenotypic information, and items about CFM-related experiences across settings. Themes were identified by qualitative analysis of responses to open-ended questions. Respondents (n = 51) included caregivers (n = 42; 90% mothers) and adults with CFM (n = 9; 78% female), who had a mean age of 45 ± 6 years. Most children were male (71%) with an average age of 7 ± 4 years. Respondents were primarily white (80%), non-Hispanic (89%), from the United States (82%), had a college degree (80%), and had private health insurance (80%). Reflecting the high rate of microtia (84%) in the sample, themes centered on the impact of hearing difficulties across settings with related language concerns. Negative social experiences were frequently described and school needs outlined. Multiple medical stressors were identified and corresponding suggestions included: providers need to be better informed about CFM, treatment coordination among specialists, and preference for a family-centered approach with reassurance, empathy, and clear communication. Advice offered to others with CFM included positive coping strategies. Overall, caregivers' and patients' responses reflected the complexity of CFM treatment. Incorporating these perspectives into routine CFM care has the potential to reduce family distress while improving their healthcare.