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

Synthesis of clinical practice guideline recommendations for the primary health care of chronic musculoskeletal pain

RATIONALE AND AIMS

The prevalence of chronic musculoskeletal pain (CMSP) is high and rising. The multidimensional impact of CMSP on individuals necessitates multidisciplinary evidence-based strategies to prevent and manage chronic pain. Primary health care (PHC) is the first point of care in many healthcare systems and evidence implementation at this point is important. We aim to describe the process of development of a comprehensive list of evidence-based recommendations derived from different high-quality clinical practice guidelines (CPGs) to inform the PHC healthcare of adults with CMSP.

METHOD

A systematic review was conducted of CPGs that focussed on PHC management of CMSP in adults. CPGs were identified by searching 13 guideline clearinghouses and five online databases. Eligible CPGs were critically appraised using Appraisal of Guidelines Research and Evaluation, Version II (AGREE II). A stepwise systematic process was followed to identify a core set of recommendations. This process comprised the following: extract recommendations; analyze recommendations; synthesize recommendations by assimilating similar recommendations; determine the strength of the body of evidence underpinning the recommendations and produce a list of synthesized recommendations.

RESULTS

Six high-quality CPGs were identified, providing 156 recommendations. These were condensed to 42 statements covering topics about the approach to care, assessment, advice and education, referral, pharmacological management, physical therapy, electrotherapy, psychological therapy, complementary therapy and self-management. The set of recommendations encompasses a person-centered approach, collaborative decision making, a biopsychosocial approach, patient education and empowerment towards self-management.

CONCLUSION

The process of developing composite recommendations from multiple CPGs enables end-users to access comprehensive information on managing CMSP in PHC settings that is not available from one singular CPG. The content and evidence base for recommendations varied between CPGs. A similar stepwise process may be used to develop a core set of recommendations for other health conditions, where multiple, diverse CPGs exist.

Strengthening prehospital clinical practice guideline development in South Africa: Reflections from guideline experts

INTRODUCTION

De novo (new) guideline development methods are well described and supported by numerous examples, including comprehensive checklists. However, alternative guideline development methods, which draw from existing up to date, high quality clinical practice guidelines instead of re-inventing the wheel, have not been adopted so readily, despite the potential efficiencies of such methods compared to de novo development. In Africa, guideline quality and rigour of development, especially for prehospital care, remains poor. This paper firstly describes the opinions of international guideline experts on the African Federation for Emergency Medicine guideline project, and secondly updates a framework for South African prehospital guideline development.

METHODS

We conducted a qualitative study of expert reviews of an evidence-based guideline development project led by the African Federation for Emergency Medicine in 2016 for prehospital care in South Africa. We purposefully sampled key international and regional guideline experts from a range of organisations. Comments and voice memos, following a terms of reference guide, were thematically analysed through manual coding.

RESULTS

A total of seven experts gave feedback. Key themes revolved around existing international clinical practice guidelines not being enough to cover context specific evidence, blurring of guideline responsibilities and output, and transparency of guideline decisions and conflicts of interest. We showcase three fit-for-purpose guideline development approaches and provide an updated alternative guideline development roadmap for low-resource settings.

CONCLUSION

In order to create clinical practice guidelines that clinicians trust and use on a daily basis to change lives, guideline developers need rigorous yet pragmatic approaches that are responsive to end-user needs. Reflecting on the African Federation for Emergency Medicine prehospital guideline development project in 2016, this paper presents key guiding themes to strengthen guideline development in low- and middle-income countries and other low-resource settings and provides an updated hybrid guideline development approach.

Strengthening prehospital clinical practice guideline implementation in South Africa: a qualitative case study

BACKGROUND

Methods on developing new (de novo) clinical practice guidelines (CPGs) have received substantial attention. However, research into alternative methods of CPG development using existing CPG documents (CPG adaptation) - a specific issue for guideline development groups in low- and middle-income countries - is sparse. There are only a few examples showcasing the pragmatic application of such alternative approaches in settings with time and budget constraints, especially in the prehospital setting. This paper aims to describe and strengthen the methods of developing prehospital CPGs using alternative guideline development methods through a case study design.

METHODS

We qualitatively explored a CPG development project conducted in 2016 for prehospital providers in South Africa as a case study. Key stakeholders, involved in various processes of the guideline project, were purposefully sampled. Data were collected from one focus group and six in-depth interviews and analysed using thematic analysis. Overarching themes and sub-themes were inductively developed and categorised as challenges and recommendations and further transformed into action points.

RESULTS

Key challenges revolved around guideline implementation as opposed to development. These included the unavoidable effect of interest and beliefs on implementing recommendations, the local evidence void, a shifting implementation context, and opposing end-user needs. Guideline development and implementation strengthening priority actions included: i) developing a national end-user document; ii) aligning recommendations with local practice; iii) communicating a clear and consistent message; iv) addressing controversial recommendations; v) managing the impact of interests, beliefs and intellectual conflicts; and vi) transparently reporting implementation decisions.

CONCLUSION

The cornerstone of a successful guideline development process is the translation and implementation of CPG recommendations into clinical practice. We highlight key priority actions for prehospital guideline development teams with limited resources to strengthen guideline development, dissemination, and implementation by drawing from lessons learnt from a prehospital guideline project conducted in South Africa.