Prioritizing guideline recommendations for implementation: a systematic, consumer-inclusive process with a case study using the Australian Clinical Guidelines for Stroke Management

Introducing re-weighted range voting in clinical practice guideline prioritization: Development and testing of the re-weighted priority-setting (REPS) tool

We aimed to develop and test a tool based on the re-weighted range voting mechanism to prioritize items (i.e. key questions) in a priority-setting assessment for clinical practice guidelines. The secondary aim was to provide methodological context of the tool. We iteratively developed the tool and used qualitative methods (i.e. think-aloud and semi-structured interviews) to test the tool's usability and make adjustments accordingly. An observational approach was used to test the tool's outcome satisfaction in a real-world priority-setting assessment within a rare-disease guideline of a European Reference Network and under four different conditions in the tool. Four guideline methodologists tested the usability of the tool. The real-world testing was performed with a guideline panel consisting of a core working group, five expertise working groups, and a working group with patient representatives. Thirty-one panel members assigned scores in the priority-setting assessment. Seventeen panel members rated the priority-setting outcome, and sixteen panel members rated the outputs generated under the four conditions. Upon initial use, guideline methodologists found the tool to be quite overwhelming. However, with some initial effort they were able to easily identify the tool's structure. Based on observations and feedback, the tool was further refined and user guidance was developed. Guideline panel members expressed (high) satisfaction with the priority-setting outcome. They particularly preferred the condition when using mean subgroup scores as input or employing aggressive penalties in the weighting method to determine the outputs. The tool generates a ranked list of items and offers flexibility for different choices in priority-setting assessments as long as its input format requirements are met. Although it is not a consensus method, the tool assists in narrowing down a set of priority items. Additional steps in the priority-setting assessment can lead to a consensus being reached regarding the final outcome.

Standardized measurement of balance and mobility post-stroke: Consensus-based core recommendations from the third Stroke Recovery and Rehabilitation Roundtable

BACKGROUND

Mobility is a key priority for stroke survivors. Worldwide consensus of standardized outcome instruments for measuring mobility recovery after stroke is an essential milestone to optimize the quality of stroke rehabilitation and recovery studies and to enable data synthesis across trials.

METHODS

Using a standardized methodology, which involved convening of 13 worldwide experts in the field of mobility rehabilitation, consensus was established through an a priori defined survey-based approach followed by group discussions. The group agreed on balance- and mobility-related definitions and recommended a core set of outcome measure instruments for lower extremity motor function, balance and mobility, biomechanical metrics, and technologies for measuring quality of movement.

RESULTS

Selected measures included the Fugl-Meyer Motor Assessment lower extremity subscale for motor function, the Trunk Impairment Scale for sitting balance, and the Mini Balance Evaluation System Test (Mini-BESTest) and Berg Balance Scale (BBS) for standing balance. The group recommended the Functional Ambulation Category (FAC, 0-5) for walking independence, the 10-meter Walk Test (10 mWT) for walking speed, the 6-Minute Walk Test (6 MWT) for walking endurance, and the Dynamic Gait Index (DGI) for complex walking. An FAC score of less than three should be used to determine the need for an additional standing test (FAC < 3, add BBS to Mini-BESTest) or the feasibility to assess walking (FAC < 3, 10 mWT, 6 MWT, and DGI are "not testable"). In addition, recommendations are given for prioritized kinetic and kinematic metrics to be investigated that measure recovery of movement quality of standing balance and walking, as well as for assessment protocols and preferred equipment to be used.

CONCLUSIONS

The present recommendations of measures, metrics, technology, and protocols build on previous consensus meetings of the International Stroke Recovery and Rehabilitation Alliance to guide the research community to improve the validity and comparability between stroke recovery and rehabilitation studies as a prerequisite for building high-quality, standardized "big data" sets. Ultimately, these recommendations could lead to high-quality, participant-specific data sets to aid the progress toward precision medicine in stroke rehabilitation.

Standardized measurement of balance and mobility post-stroke: Consensus-based core recommendations from the third Stroke Recovery and Rehabilitation Roundtable

BACKGROUND

Mobility is a key priority for stroke survivors. Worldwide consensus of standardized outcome instruments for measuring mobility recovery after stroke is an essential milestone to optimize the quality of stroke rehabilitation and recovery studies and to enable data synthesis across trials.

METHODS

Using a standardized methodology, which involved convening of 13 worldwide experts in the field of mobility rehabilitation, consensus was established through an a priori defined survey-based approach followed by group discussions. The group agreed on balance- and mobility-related definitions and recommended a core set of outcome measure instruments for lower extremity motor function, balance and mobility, biomechanical metrics, and technologies for measuring quality of movement.

RESULTS

Selected measures included the Fugl-Meyer Motor Assessment lower extremity subscale for motor function, the Trunk Impairment Scale for sitting balance, and the Mini Balance Evaluation System Test (Mini-BESTest) and Berg Balance Scale (BBS) for standing balance. The group recommended the Functional Ambulation Category (FAC, 0-5) for walking independence, the 10-meter Walk Test (10 mWT) for walking speed, the 6-Minute Walk Test (6 MWT) for walking endurance, and the Dynamic Gait Index (DGI) for complex walking. An FAC score of less than three should be used to determine the need for an additional standing test (FAC < 3, add BBS to Mini-BESTest) or the feasibility to assess walking (FAC < 3, 10 mWT, 6 MWT, and DGI are "not testable"). In addition, recommendations are given for prioritized kinetic and kinematic metrics to be investigated that measure recovery of movement quality of standing balance and walking, as well as for assessment protocols and preferred equipment to be used.

CONCLUSIONS

The present recommendations of measures, metrics, technology, and protocols build on previous consensus meetings of the International Stroke Recovery and Rehabilitation Alliance to guide the research community to improve the validity and comparability between stroke recovery and rehabilitation studies as a prerequisite for building high-quality, standardized "big data" sets. Ultimately, these recommendations could lead to high-quality, participant-specific data sets to aid the progress toward precision medicine in stroke rehabilitation.

Barriers and facilitators to outcome measurement and treatment practices in aphasia rehabilitation in the USA: a mixed methods approach using the Theoretical Domains Framework

PURPOSE

To identify clinician-perceived barriers and facilitators to the delivery of outcome measurement and evidence-based treatment practices and integration of these practices in aphasia rehabilitation.

MATERIALS AND METHODS

Using a convergent mixed methods design, aphasia clinicians (n = 87) across care settings in the United States completed an online survey designed within the Theoretical Domains Framework (TDF). Participants responded to open-ended questions and rated Likert scale statements. Qualitative data were analyzed using content analysis and quantitative data were summarized using descriptive statistics.

RESULTS

Factors related to the TDF domain of "environmental context and resources" (priority and productivity demands; characteristics of resources) were cited as primary barriers in 70% of qualitative responses for both outcome and treatment practices and were consistent with Likert rating statements. Facilitators were associated with TDF domains of "memory, attention, decision-making" (decision-making processes), "knowledge" (awareness of evidence) and "social influences" (client and caregiver preferences).

CONCLUSIONS

Organizational-level factors and the misalignment of the research evidence with clinical needs are barriers to delivering evidence-based care in aphasia rehabilitation. Theoretically informed strategies such as establishing organizational infrastructure for practice change, developing clinically relevant evidence through research-practice partnerships, and implementing algorithms to support clinical decision-making can address barriers and leverage facilitators.

How should we measure physical activity after stroke? An international consensus

BACKGROUND

Physical activity is important for secondary stroke prevention. Currently, there is inconsistency of outcomes and tools used to measure physical activity following stroke.

AIM

To establish internationally agreed recommendations to enable consistent measurement of post-stroke physical activity.

METHODS

Stroke survivors and carers were surveyed online once regarding what is important in physical activity measurement. Three survey rounds with expert stroke researchers and clinicians were conducted using Keeney's Value-Focused Thinking Methodology. Survey 1 identified physical activity tools, outcomes, and measurement considerations which were ranked in Survey 2. Consensus recommendations on tools were then formulated by the consensus group based on survey responses. In Survey 3, participants reviewed ranked results and evidence gathered to determine their support for consensus recommendations.

RESULTS

Twenty-five stroke survivors, 5 carers, 18 researchers, and 17 clinicians from 16 countries participated. Time in moderate-vigorous physical activity and step count were identified as the most important outcomes to measure. Key measurement considerations included the ability to measure across frequency, intensity, duration domains in real-world settings; user-friendliness, comfort, and ability to detect changes. Consensus recommendations included using the Actigraph, Actical, and Activ8 devices for physical activity intensity; ActivPAL for duration and Step Activity Monitor for frequency; and the IPAQ and PASE questionnaires. Survey 3 indicated 100% support for device and 96% for questionnaire recommendations.

CONCLUSIONS

These consensus recommendations can guide selection of physical activity measurement tools and outcomes. Tool selection will depend on measurement purpose, user-knowledge, and resources. Comprehensive measurement requires the use of devices and questionnaires.

Is learning being supported when information is provided to informal carers during inpatient stroke rehabilitation? A qualitative study

Purpose: To explore how health professionals provide information to informal carers during inpatient stroke rehabilitation and whether these practices align with adult learning principles.Methods: Informal carers and survivors of stroke who had completed inpatient rehabilitation, and health professionals working in inpatient stroke rehabilitation were interviewed. Directed qualitative content analysis was conducted using an adult learning model, to determine how closely reported practices aligned to adult learning principles.Results: 14 carers, 6 survivors of stroke and 17 health professionals participated. Carers (79% female, 57% spouse/partner) reported having incomplete knowledge during rehabilitation, lacking information about mechanisms of stroke recovery, rehabilitation processes, long-term effects of stroke, and navigating post-discharge services. Health professionals supported carers to address their learning needs related to safety of caring for stroke survivors. Carers indicated they were responsible for their own non-safety related learning. Health professionals tended not to check carers' understanding of information provided nor offer learning opportunities beyond written or verbal information.Conclusions: Health professionals consistently provide certain information to carers during inpatient rehabilitation, but adult learning principles are not routinely applied when information is provided. Fostering adult learning among informal carers may improve preparedness of carers to support stroke survivors after discharge from inpatient rehabilitation.

What is 'successful rehabilitation'? A multi-stakeholder nominal group technique study to inform rehabilitation outcome measurement

OBJECTIVE

To explore how stakeholders in rehabilitation conceptualise 'successful rehabilitation', to inform the development of a minimum dataset and core outcomes for sub-acute rehabilitation.

DESIGN

Qualitative consensus study using the nominal group technique.

SETTING

Online focus groups.

PARTICIPANTS

Consumer representatives (n = 7), clinicians (n = 15), and health service managers (n = 9) from Australia.

INTERVENTION

Participants responded to the question, 'What does successful rehabilitation look like?'. Following item generation, they prioritised their top five responses, allocating 100 points across items to denote relative importance.

MAIN MEASURES

Prioritised responses were analysed across stakeholder groups using qualitative content analysis.

RESULTS

Ten themes were identified. 'Successful rehabilitation' is: (1) person and family centred; (2) effective; (3) inter-professional; (4) accessible; (5) goal oriented with meaningful outcomes; (6) connected to the continuum of care; (7) evidence-based and supportive of innovation and research; (8) appropriately funded and skilled; (9) satisfying and engaging; and (10) safe.

CONCLUSIONS

Stakeholder-defined 'successful rehabilitation' aligned with principles of value-based care and evidence-based rehabilitation. Provision and receipt of person and family centred care was the most important indicator of successful rehabilitation. Measures of success should include indicators of structure, process, outcome, and experience, and be conducted at multiple time-points.

Methods for living guidelines: early guidance based on practical experience. Paper 3: selecting and prioritizing questions for living guidelines

OBJECTIVES

This article is part of a series on methods for living guidelines, consolidating practical experiences from developing living guidelines. It focuses on methods for identification, selection, and prioritization of clinical questions for a living approach to guideline development.

STUDY DESIGN AND SETTING

Members of the Australian Living Evidence Consortium, the National Institute of Health and Care Excellence and the US Grading of Recommendations, Assessment, Development and Evaluations Network, convened a working group. All members have expertize and practical experience in the development of living guidelines. We collated methods, documents on prioritization from each organization's living guidelines, conducted interviews and held working group discussions. We consolidated these to form best practice principles which were then edited and agreed on by the working group members.

RESULTS

We developed best practice principles for (1) identification, (2) selection, and (3) prioritization, of questions for a living approach to guideline development. Several different strategies for undertaking prioritizing questions are explored.

CONCLUSION

The article provides guidance for prioritizing questions in living guidelines. Subsequent articles in this series explore consumer involvement, search decisions, and methods decisions that are appropriate for questions with different priority levels.

Feasibility of national living guideline methods: the Australian Stroke Guidelines

OBJECTIVE

Maintaining clinical guideline currency has been one challenge to traditional guideline development. This paper describes the methods used to maintain a large national guideline for stroke management.

STUDY DESIGN AND SETTING

The Australian Stroke Clinical Guidelines are developed to meet Australian National Health and Medical Research Council (NHMRC) standards. Monthly surveillance is conducted for new systematic reviews and randomised controlled studies. Included studies undergo data extraction followed by preparation of updated evidence-to-decision frameworks which are used to inform updates, or development of new recommendations. Small writing groups made up of clinical experts and those with lived experience review and agree on changes, which are finally reviewed by a multidisciplinary Guidelines Steering Group. Draft changes are developed and published using the online MAGICapp platform, with dissemination and promotion via traditional methods as well as social media.

RESULTS

Each month approximately 350 abstracts are considered, covering 96 clinical topics and taking on average 16 hours to review. There have been four major guideline updates covering 34 new and updated recommendations.

CONCLUSION

It is feasible to use 'living' methods to maintain the Australian Clinical Guidelines for Stroke Management. Further work is now needed to understand the impact of living guidelines.