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De Leo A, Bloxsome D, Bayes S. Approaches to clinical guideline development in healthcare: a scoping review and document analysis. BMC Health Serv Res 2023; 23:37. [PMID: 36647085 PMCID: PMC9841716 DOI: 10.1186/s12913-022-08975-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 12/15/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Over the past decade, an industry has emerged around Clinical Practice Guideline (CPG) development in healthcare, which has increased pressure on guideline-producing organisations to develop CPGs at an accelerated rate. These are intended to improve the quality of care provided to patients while containing healthcare costs and reducing variability in clinical practice. However, this has inadvertently led to discrepancies in CPG recommendations between health organisations, also challenging healthcare providers who rely on these for decision-making and to inform clinical care. From a global perspective, although some countries have initiated national protocols regarding developing, appraising and implementing high-quality CPGs, there remains no standardised approach to any aspect of CPG production. METHODS A scoping review of the literature and document analysis were conducted according to Joanna Brigg's Institute methodology for scoping reviews. This comprised two qualitative methods: a comprehensive review of the literature (using CINAHL, Scopus and PubMeD) and a document analysis of all national and international guideline development processes (manual search of health-related websites, national/international organisational health policies and documents). RESULTS A set of clear principles and processes were identified as crucial to CPG development, informing the planning, implementation and dissemination of recommendations. Fundamentally, two common goals were reported: to improve the quality and consistency of clinical practice (patient care) and to reduce the duplication or ratification of low-grade CPGs. CONCLUSIONS Consultation and communication between CPG working parties, including a wide range of representatives (including professional organisations, regional and local offices, and relevant national bodies) is essential. Further research is required to establish the feasibility of standardising the approach and disseminating the recommendations.
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Affiliation(s)
- Annemarie De Leo
- grid.1038.a0000 0004 0389 4302Edith Cowan University, 270 Joondalup Drive, Perth, WA Australia
| | - Dianne Bloxsome
- grid.1038.a0000 0004 0389 4302Edith Cowan University, 270 Joondalup Drive, Perth, WA Australia
| | - Sara Bayes
- grid.411958.00000 0001 2194 1270Australian Catholic University, 8-14 Brunswick St. Fitzroy, Victoria, Australia
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Wilkinson M, Hofman KJ, Young T, Schmidt BM, Kredo T. Health economic evidence in clinical guidelines in South Africa: a mixed-methods study. BMC Health Serv Res 2021; 21:738. [PMID: 34304743 PMCID: PMC8310693 DOI: 10.1186/s12913-021-06747-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/30/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Evidence-informed clinical practice guidelines (CPGs) are useful tools to inform transparent healthcare decision-making. Consideration of health economic evidence (HEE) during CPG development in a structured manner remains a challenge globally and locally. This study explored the views, current practice, training needs and challenges faced by CPG developers in the production and use of HEE for CPGs in South Africa. METHODS This mixed-methods study comprised an online survey and a focus group discussion. The survey was piloted and subsequently sent to CPG role players - evidence reviewers, CPG panellists, academics involved with training in relevant disciplines like health economics and public health, implementers and funders. The focus group participants hold strategic roles in CPG development and health economic activities nationally. The survey evaluated mean values, measures of variability, and percentages for Likert scales, while narrative components were thematically analysed. Focus group data were manually coded, thematically analysed and verified. RESULTS The survey (n = 55 respondents to 245 surveys distributed) and one focus group (n = 5 participants from 10 people invited) occurred between October 2018 and February 2019. We found the most consistent reason why HEE should inform CPG decisions was 'making more efficient use of limited financial resources'. This was explained by numerous context and methodological barriers. Focus groups participants noted that consideration of complex HEE are not achievable without bolstering skills in applying evidence-based medicine principles. Further concerns include lack of clarity of standard methods; inequitable and opaque topic selection across private and public sectors; inadequate skills of CPG panel members to use HEE; and the ability of health economists to communicate results in accessible ways. Overall, in the absence of clarity about process and methods, politics and interests may drive CPG decisions about which interventions to implement. CONCLUSIONS HEE should ideally be considered in CPG decisions in South Africa. However, this will remain hampered until the CPG community agree on methods and processes for using HEE in CPGs. Focused investment by national government to address the challenges identified by the study is imperative for a better return on investment as National Health Insurance moves forward.
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Affiliation(s)
- Maryke Wilkinson
- Cochrane South Africa, South African Medical Research Council, Tygerberg, Cape Town, South Africa.
| | - Karen J Hofman
- SAMRC Centre for Health Economics and Decision Science, PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Taryn Young
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, Cape Town, South Africa
| | - Bey-Marrié Schmidt
- Cochrane South Africa, South African Medical Research Council, Tygerberg, Cape Town, South Africa.,School of Public Health, University of the Western Cape, Bellville, Cape Town, South Africa
| | - Tamara Kredo
- Cochrane South Africa, South African Medical Research Council, Tygerberg, Cape Town, South Africa.,Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, Cape Town, South Africa
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Balinska MA, Watts RA. The value of case reports in democratising evidence from resource-limited settings: results of an exploratory survey. Health Res Policy Syst 2020; 18:84. [PMID: 32690034 PMCID: PMC7370517 DOI: 10.1186/s12961-020-00592-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 06/24/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Following a knowledge management analysis, Médecins Sans Frontières (MSF) - a medical humanitarian non-governmental organisation (NGO) - identified significant loss of medical knowledge from the field, owing primarily to the absence of a platform on which to share clinical lessons learned in humanitarian and resource-limited settings (HRLS). Wishing to address these missed opportunities to retain important scientific and pragmatic knowledge, the NGO has begun to actively encourage its clinicians to publish case reports/series that bring new and/or practical insights of benefit to patients and population groups. In parallel, we wished to obtain a clearer understanding of how case reports (CRs)/series can best play their role as 'first-line evidence' from HRLS, especially in areas suffering from a significant lack of data. METHODS We developed a survey with closed and open questions on 'The value of CRs from HRLS' to explore primarily (1) the reasons why this form of evidence from HRLS is often lacking, (2) what makes a case report/series worth sharing with the wider global health community, and (3) how we can ensure that published case reports/series reach their target audience. RESULTS Over a 6-month period, 1115 health professionals responded to the survey. Participants included clinicians and public health specialists from all over the world, with a majority based in Africa. The main reason cited for the dearth of CRs from HRLS was that practitioners are simply not writing and/or submitting reports (as versus having their papers rejected) due mainly to (1) a lack of skills and (2) time constraints. A large majority of respondents felt the CRs are a valuable tool for HRLS given their ability to discuss how cases are managed with rudimentary means as well as to draw attention to emerging or underestimated public health problems and neglected populations. CONCLUSION We conclude that the clinical knowledge gained in resource-challenged settings is being underutilised in the interest of patients and global health. Consequently, clinicians in HRLS need greater access to basic training in scientific investigation and writing in addition to awareness as to the potential value of sharing their clinical experience with a view to broadening evidence production from high-income to low-income settings.
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Affiliation(s)
- Marta A Balinska
- Vienna Evaluation Unit, Médecins Sans Frontières Austria, Taborstrasse 10, 1020, Vienna, Austria.
| | - Richard A Watts
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
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Stander J, Grimmer K, Brink Y. Factors influencing clinical practice guideline uptake by South African physiotherapists: A qualitative investigation of barriers and facilitators. J Eval Clin Pract 2020; 26:728-737. [PMID: 31190423 DOI: 10.1111/jep.13182] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 04/22/2019] [Accepted: 04/22/2019] [Indexed: 11/29/2022]
Abstract
RATIONALE Clinical practice guidelines (CPGs) should provide busy health care professionals with easy-to-use tools that support efficient uptake of current best evidence in daily clinical practice. However, CPG uptake rarely occurs at the speed of evidence production. The aim of this study was to explore the factors influencing CPG uptake among South African (SA) physiotherapists (PTs). METHOD An exploratory, descriptive qualitative study design was used, within an interpretative research paradigm. A phenomenological approach was taken, as the study aimed to explore the phenomenon of CPG uptake by SA PTs and how the themes and subthemes related to each other within this phenomenon. Semistructured interviews were undertaken via telephone calls that were audiotaped and independently transcribed. An inductive and deductive thematic content analysis approach was taken where the transcript content was analysed by hand. FINDINGS Thirty-one PTs from the private, public, and education sectors participated in the interviews. The main themes identified were resources, training, and organizational factors. The SA PT workforce, particularly that in the public sector, is limited and patient load and need is high. Time to implement and stay up-to-date with current evidence were barriers for many interviewees. Participants also perceived CPG uptake as not being financially rewarding. Training in CPG uptake was mostly perceived as a facilitator, and the PTs felt that they would be more inclined to implement CPGs if they felt more confident in how to source and use CPGs, particularly if they were incentivized to undertake such training. Roles, responsibilities, and power in the health care team were perceived as being both organizational barriers and, conversely, facilitators, depending on work environments. CONCLUSIONS The findings of this study generally concur with previous studies about PT barriers to CPG uptake; however, it provides novel information on barrier contexts in one LMIC with complex PT service delivery.
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Affiliation(s)
- Jessica Stander
- Division of Physiotherapy, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Karen Grimmer
- Division of Physiotherapy, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Yolandi Brink
- Division of Physiotherapy, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Kredo T, Cooper S, Abrams AL, Muller J, Schmidt BM, Volmink J, Atkins S. 'Building on shaky ground'-challenges to and solutions for primary care guideline implementation in four provinces in South Africa: a qualitative study. BMJ Open 2020; 10:e031468. [PMID: 32474422 PMCID: PMC7264636 DOI: 10.1136/bmjopen-2019-031468] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 03/24/2020] [Accepted: 04/03/2020] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES Clinical guidelines support evidence-informed quality patient care. Our study explored perspectives of South African subnational health managers regarding barriers to and enablers for implementation for all available primary care guidelines. DESIGN We used qualitative research methods, including semistructured, individual interviews and an interpretative perspective. Thematic content analysis was used to develop data categories and themes. SETTING We conducted research in four of nine South African provinces with diverse geographic, economic and health system arrangements (Eastern Cape, Western Cape, KwaZulu-Natal, Limpopo). South Africa is a middle-income country with high levels of inequality. The settings represented public sector rural and peri-urban health facilities. PARTICIPANTS Twenty-two participants with provincial and district health management roles, that comprised implementation and/or training on primary care guidelines, were included. RESULTS Participants recommended urgent consideration of health system challenges, particularly financial constraints, impacting on access to the guidelines themselves and to medical equipment and supplies necessary to adhere to guidelines. They suggested that overcoming service delivery gaps requires strengthening of leadership, clarification of roles and enhanced accountability. Participants suggested that inadequate numbers of skilled clinical staff hampered guideline use and, ultimately, patient care. Quality assurance of training programmes for clinicians-particularly nurses-interdisciplinary training, and strengthening post-training mentorship were recommended. Furthermore, fit-for-purpose guideline implementation necessitates considering the unique settings of facilities, including local culture and geography. This requires guideline development to include guideline end users. CONCLUSIONS Guidelines are one of the policy tools to achieve evidence-informed, cost-effective and universal healthcare. But, if not effectively implemented, they have no impact. Subnational health managers in poorly resourced settings suggested that shortcomings in the health system, along with poor consultation with end users, affect implementation. Short-term improvements are possible through increasing access to and training on guidelines. However, health system strengthening and recognition of socio-cultural-geographic diversity are prerequisites for context-appropriate evidence-informed practice.
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Affiliation(s)
- Tamara Kredo
- Cochrane South Africa, South African Medical Research Council, Tygerberg, South Africa
- Department of Medicine, Division of Clinical Pharmacology, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Sara Cooper
- Cochrane South Africa, South African Medical Research Council, Tygerberg, South Africa
- School of Public Health and Family Medicine, University of Cape Town Faculty of Health Sciences, Observatory, Western Cape, South Africa
| | - Amber Louise Abrams
- Cochrane South Africa, South African Medical Research Council, Tygerberg, South Africa
| | - Jocelyn Muller
- Cochrane South Africa, South African Medical Research Council, Tygerberg, South Africa
| | - Bey-Marrié Schmidt
- Cochrane South Africa, South African Medical Research Council, Tygerberg, South Africa
| | - Jimmy Volmink
- Cochrane South Africa, South African Medical Research Council, Tygerberg, South Africa
- Deans office and Centre for Evidence Based Health Care, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Salla Atkins
- New Social Research and Faculty of Social Sciences, Tampere University, Tampere, Pirkanmaa, Finland
- Department of Public Health Sciences, Karolinska Institute, Stockholm, Stockholm County, Sweden
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Stander J, Grimmer K, Brink Y. A user-friendly clinical practice guideline summary for managing low back pain in South Africa. SOUTH AFRICAN JOURNAL OF PHYSIOTHERAPY 2020; 76:1366. [PMID: 32161826 PMCID: PMC7059441 DOI: 10.4102/sajp.v76i1.1366] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 10/02/2019] [Indexed: 12/29/2022] Open
Abstract
Background Clinical practice guidelines (CPGs) provide conveniently packaged evidence-based recommendations to inform clinical decisions. However, intended end-users often do not know how to source, appraise, interpret or choose among CPGs. Moreover, it can be confusing when recommendations on the same topic differ among CPGs, in wording, intent and underpinning evidence. Objectives This article reports on the processes of: (1) identifying current CPGs for acute and subacute low back pain (LBP) to fit the needs of South African physiotherapists, (2) collating and summarising CPG recommendations to produce a user-friendly end-user product and (3) testing the utility of the summary CPG document on South African physiotherapy clinicians to efficiently determine acceptability, appropriateness and feasibility to inform clinical decision-making. Method An adapted approach was followed by systematically searching online CPG repositories and online databases for LBP CPGs; screening and critically appraising identified CPGs; summarising recommendations from relevant CPGs and organising them into clinical practice activities. Feedback on utility was obtained from 11 physiotherapists. Results Three high-quality, international CPGs provided 25 recommendations on the assessment and management of acute and subacute LBP relevant to South African physiotherapy practice. They were organised into 10 headings. Physiotherapy user feedback suggested that this document would assist in clinical decision-making. Conclusion Organised recommendations extracted from multiple, relevant CPGs provide an end-user-friendly resource for physiotherapists treating LBP. Clinical implications Collated and organised CPG recommendations may effectively assist South African physiotherapists’ clinical decision-making in assessing and managing patients with acute and subacute LBP.
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Affiliation(s)
- Jessica Stander
- Division of Physiotherapy, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Karen Grimmer
- Division of Physiotherapy, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Yolandi Brink
- Division of Physiotherapy, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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