Developing a Clinician Friendly Tool to Identify Useful Clinical Practice Guidelines: G-TRUST

Indicators of the dimensions of trust (and mistrust) in early primary care practice: a qualitative study

BACKGROUND

Trust occurs when persons feel they can be vulnerable to others because of the sincerity, benevolence, truthfulness and sometimes the competence they perceive. This project examines the various types of trust expressed in written reflections of developing healthcare clinicians. Our goal is to understand the roles trust plays in residents' self-examination and to offer insight from relationship science to inform the teaching and clinical work for better trust in healthcare.

METHODS

We analyzed 767 reflective writings of 33 residents submitted anonymously, to identify explicit or implicit indicators attention to trust or relationship development. Two authors independently coded the entries based on inductively identified dimensions. Three authors developed a final coding structure that was checked against the entries. These codes were sorted into final dimensions.

RESULTS

We identified 114 written reflections that contained one or more indicators of trust. These codes were compiled into five code categories: Trust of self/trust as the basis for confidence in decision making; Trust of others in the medical community; Trust of the patient and its effect on clinician; Assessment of the trust of them exhibited by the patient; and Assessment of the effect of the patient's trust on the patient's behavior.

DISCUSSION

Broadly, trust is both relationship-centered and institutionally situated. Trust is a process, built on reciprocity. There is tacit acknowledgement of the interplay among what the residents do is good for the patient, good for themselves, and good for the medical institution. An exclusive focus on moments in which trust is experienced or missed, as well as only on selected types of trust, misses this complexity.

CONCLUSION

A greater awareness of how trust is present or absent could lead to a greater understanding and healthcare education for beneficial effects on clinicians' performance, personal and professional satisfaction, and improved quality in patients' interactions.

Conflicts of Interest in Psychopharmacology Textbooks

While most medical journals require disclosures of industry payments to authors and editors, there is no requirement for textbooks. In this study we evaluated nine well-known psychopharmacology textbooks to identify payments to their writers and editors. Two-thirds of the textbooks had at least one editor or author who received personal payments from one or more pharmaceutical companies, for a total of 11,021,409 USD paid to 11 of 21 editors/authors over a seven-year period. Much of this money was paid to a single author but 24% of the writers received over 75,000 USD each over this time period. There are several psychopharmacology textbooks authored by writers without apparent financial conflicts of interest. Just as with medical journals, medical textbooks should be transparent about payments made to their authors and editors.

Methodological approaches for developing, reporting, and assessing evidence-based clinical practice guidelines: A systematic survey

OBJECTIVE

To produce a mapping and feature summary of approaches and tools available for the CPG community to develop, report, or assess four types of CPGs: (1) Standard original (or de novo) CPG, (2) Rapid original CPG, (3) Adapted/adopted CPGs, and (4) Updated CPGs.

STUDY DESIGN

The systematic literature search was conducted using Embase and PubMed, covering the period from January 2010 to October 13 2020. Two websites that collect and recommend approaches/tools to develop, report, or assess CPGs were also searched: Guidelines International Network and Equator Network. We screened the search results to include methodological papers that aimed to develop specific approaches/tools to develop, report, or assess any of the aforementioned four CPG types.

RESULTS

Among 10,581 citations, 46 papers reporting 46 approaches/tools were included. Of these 46 approaches/tools, 33 were about CPG development, seven were for CPG reporting, and six for CPG assessment. Among the 33 development approaches/tools, 26 did not state usability or validity information; but nine from 13 reporting or assessment approaches/tools did.

CONCLUSIONS

This study provides a mapping and feature summary of the current available approaches/tools, which serves to improve users' understanding to pave the way for informed choice and application.

Addressing barriers to evidence-based medicine in pediatric surgery: an introduction to the Canadian Association of Paediatric Surgeons Evidence-Based Resource

Background

Pediatric surgical practice lags behind medicine in presence and use of evidence, primarily due to time constraints of using existing tools that are not specific to pediatric surgery, lack of sufficient patient data and unstructured pediatric surgery training methods.

Method

We developed, disseminated and tested the effectiveness of an evidence-based resource for pediatric surgeons and researchers that provides brief, informative summaries of quality-assessed systematic reviews and meta-analyses on conflicting pediatric surgery topics.

Results

Responses of 91 actively practicing surgeons who used the resource were analysed. The majority of participants found the resource useful (75%), improved their patient care (66.6%), and more than half (54.2%) found it useful in identifying research gaps. Almost all participants reported that the resource could be used as a teaching tool (93%).

Conclusion

Lack of awareness of the resource is the primary barrier to its routine use, leading to potential calls for more active dissemination worldwide. Users of the Canadian Association of Paediatric Surgeons Evidence-Based Resource find that the summaries are useful, identify research gaps, help mitigate multiple barriers to evidence-based medicine, and may improve patient care.

What Determines the Quality of Rehabilitation Clinical Practice Guidelines?: An Overview Study

OBJECTIVE

The aim of the study was to determine what factors determine the quality of rehabilitation clinical practice guidelines.

DESIGN

Six databases were searched for articles that had applied the Appraisal of Guidelines for Research & Evaluation II quality assessment tool to rehabilitation clinical practice guidelines. The 573 deduplicated abstracts were independently screened by two authors, resulting in 81 articles, the full texts of which were independently screened by two authors for Appraisal of Guidelines for Research & Evaluation II application to rehabilitation clinical practice guidelines, resulting in a final selection of 40 reviews appraising 504 clinical practice guidelines. Data were extracted from these by one author and checked by a second. Data on each clinical practice guideline included the six Appraisal of Guidelines for Research & Evaluation II domain scores, as well as the two Appraisal of Guidelines for Research & Evaluation II global evaluations.

RESULTS

All six Appraisal of Guidelines for Research & Evaluation II domain scores were statistically significant predictors of overall clinical practice guideline quality rating; D3 (rigor of development) was the strongest and D1 (scope and purpose) the weakest (overall model P < 0.001, R2 = 0.53). Five of the six domain scores were significant predictors of the clinical practice guideline use recommendation, with D3 the strongest predictor and D5 (applicability) the weakest (overall model P < 0.001, pseudo R2 = 0.53).

CONCLUSIONS

Quality of rehabilitation clinical practice guidelines may be improved by addressing key domains such as rigor of development.

Endorsement of clinical practice guidelines: Criteria from the College of Family Physicians of Canada

OBJECTIVE

To refine the process for endorsement of guidelines and establish the expectations of the College of Family Physicians of Canada (CFPC) regarding the quality and relevance of clinical practice guidelines targeting family physicians and their patients.

COMPOSITION OF THE COMMITTEE

Initially, a group of 6 CFPC staff and selected College members reviewed the previous process for endorsement with the aim of providing a new direction, if needed. The work was then assumed by the Guideline and Knowledge Translation Expert Working Group, a purposefully selected group of 9 family physicians from across Canada with expertise in research, evidence, guidelines, knowledge translation, and continuing professional development and education.

METHODS

The initial task force reviewed the endorsement process and identified areas for improvement. A draft new process and core criteria for high-quality guidelines were developed. This was approved by the CFPC board. A Guideline and Knowledge Translation Expert Working Group was then formed to further refine the process and the criteria. Multiple resources were used to inform the criteria. The Guideline and Knowledge Translation Expert Working Group will manage the endorsement process of external submitted guidelines, as well as provide high-level guidance to the CFPC regarding in-house guidelines and continuing professional development content.

REPORT

This article provides the expectations of the CFPC regarding clinical practice guidelines and describes in detail the process and criteria for endorsement. Key principles include family physician involvement and guideline funding unlikely to introduce bias, with most criteria falling under 4 themed areas: relation to family medicine, CFPC values, patient engagement and decision making, and scientific rigour. The Guideline and Knowledge Translation Expert Working Group will report to the CFPC board at least once a year. It is hoped that this fully transparent process and these criteria will help advance the quality and standards of clinical practice guideline production in Canada.

CONCLUSION

A comprehensive but reasonable list has been provided that reflects the best standards and recommendations and is consistent with the CFPC's values while recognizing the landscape of guideline development for its national partners and colleagues. As with all processes, careful consideration and evaluation will be essential.

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Objectif

Parfaire le processus de validation des lignes directrices et établir les attentes du Collège des médecins de famille du Canada (CMFC) quant à la qualité et à la pertinence des lignes directrices de pratique clinique à l’intention des médecins de famille et de leurs patients.

Composition du comité

Au départ, un groupe de 6 personnes, employés et membres choisis du CMFC, ont révisé le précédent processus de validation dans le but de lui donner une nouvelle orientation, au besoin. Le Groupe de travail d’experts sur les lignes directrices et le transfert des connaissances a ensuite pris le relais; ce groupe est composé de 9 médecins de famille sélectionnés avec soin partout au Canada qui sont expérimentés dans les domaines de la recherche, des données probantes, des lignes directrices, du transfert des connaissances, ainsi que du perfectionnement professionnel continu et de l’éducation.

Méthodologie

Le groupe de travail initial s’est penché sur le processus de validation et a relevé les domaines pouvant être améliorés. L’ébauche d’un nouveau processus et de critères fondamentaux pour des lignes directrices de bonne qualité a été rédigée et approuvée par le Conseil d’administration du CMFC. Un Groupe de travail d’experts sur les lignes directrices et le transfert des connaissances a ensuite été formé pour peaufiner davantage le processus et les critères. Les critères s’appuient sur plusieurs ressources. Le Groupe de travail d’experts sur les lignes directrices et le transfert des connaissances aura la responsabilité de gérer le processus de validation des lignes directrices externes soumises, ainsi que de fournir au CMFC des conseils de haut niveau sur les lignes directrices internes et le contenu du perfectionnement professionnel continu.

Rapport

Cet article présente les attentes du CMFC en matière de lignes directrices de pratique clinique, et décrit en détail le processus et les critères de validation. Les principes fondamentaux sont la participation des médecins de famille et le financement des lignes directrices qui est peu susceptible d’introduire un biais, et la plupart des critères s’inscrivent sous 4 thèmes : la relation avec la médecine familiale; les valeurs du CMFC; l’engagement et la prise de décision des patients; et la rigueur scientifique. Le Groupe de travail d’experts sur les lignes directrices et le transfert des connaissances présentera ses résultats au Conseil d’administration du CMFC au moins une fois l’an. L’on souhaite que ce processus complètement transparent et ces critères fassent progresser la qualité et les normes qui régissent la production des lignes directrices de pratique clinique au Canada.

Conclusion

Une liste exhaustive, mais raisonnable, reflète les meilleures normes et recommandations, et respecte les valeurs du CMFC tout en reconnaissant le contexte de rédaction des lignes directrices pour ses partenaires et ses collègues à l’échelle nationale. Comme c’est le cas pour tous les processus, l’examen et l’évaluation approfondis seront essentiels.

Participation and consultation engagement strategies have complementary roles: A case study of patient and public involvement in clinical practice guideline development

Background

Patient and public involvement (PPI) is recommended when developing high‐quality clinical practice guidelines, but the effects of different PPI strategies are largely unstudied.

Objective

To assess the impact of participation and consultation strategies on guideline question development.

Design

Instrumental case study design.

Setting and participants

This study used a clinical practice guideline in development by the American Academy of Neurology. A patient, two caregivers and a dementia advocate participated in the guideline development group alongside clinicians. The guideline protocol was posted for public consultation for 30 days.

Interventions studied

Participation (patient representatives on the guideline development group) and consultation (public comment, survey) PPI strategies.

Main outcome measures

Public comment responses and guideline development group meeting transcripts were analysed descriptively. Transcript quotes were compared to the conceptual model of PPI in guideline development. The effects of participation and consultation strategies within the guideline case were compared.

Results

Participation strategies shaped discussions, set a patient‐centred scope, highlighted personal aspects of disease, affected how professionals viewed PPI, identified issues overlooked by medical professionals, and contributed to selecting patient‐relevant guideline populations and outcomes. Professionals responded to public comment more than patient representatives. Patient survey participants confirmed the priorities voiced by patient representatives on the guideline development group. Final guideline questions included populations and outcomes promoted by patient representatives despite negative feedback from professional public commenters.

Discussion and conclusions

Participation and consultation PPI strategies have different advantages. Congruence between strategies increases the strength of the patient voice. Guideline developers should prioritize using both strategies for successful PPI.

Pulmonary hypertension in paediatrics. A feasible approach to bridge the gap between real world and guidelines

Pulmonary hypertension (PH) is quite infrequent in paediatric age and its most common aetiologies include idiopathic pulmonary arterial hypertension, PH related to congenital heart diseases, bronchopulmonary dysplasia (chronic lung disease), persistence of pulmonary hypertension of the newborn, and congenital diaphragmatic hernia. The developed for adult patients PH classification shows limitations when applied to paediatric subjects, since the underlying causes are markedly different between the two ages. In 2011, the Pulmonary Vascular Research Institute Panama Task Force outlined the first specific paediatric pulmonary hypertensive vascular disease diagnostic classification, including 10 main categories and 109 subcategories, thus testifying PH complex pathophysiology during newborns/children growth and development. The unique, distinctive features of paediatric PH were recognized also during the fifth World Symposium on Pulmonary hypertension in 2013 and then confirmed in the recent 2018 sixth World Symposium. For the sake of uniformity, an attempt to adapt the adult classification to paediatric patients was made. However, all these commendable classifications are very complex and may be not of quick comprehension for clinicians. A clinical simpler and simplified method is now suggested, comprising only five groups: Neonatal, Cardiac, Developmental, Idiopathic, and Syndromic PH. This approach is not aimed at replacing the already existing classifications, but is mainly based on the kind of specialized physician (neonatologist, paediatric cardiologist, paediatrician, pulmonologist, general practitioner) who first faces and looks after the child with suspected PH. What is dramatically known is that paediatric PH is a severe disease which, when untreated or undertreated, may lead to increased morbidity and mortality.