Ch 11 Flashcards
Clinical Practice Guidelines
◦The Institute of Medicine defines CPG as, “systematically developed statements that assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.” (Field & Lohr, 1992; Canadian Medical Association, 1994)
◦Best approach to development is to combine evidence-based and expert consensus.
Clinical Practice Guideline Development Process
1.Assemble a development team.
2.Define the clinical question.
3.Define current clinical practice.
4.Devise and document a strategy to locate the best quality evidence on the clinical question, as defined.
5.Identify a strategy for evaluating quality of the available evidence.
6. Identify a process for documenting specific conclusions or recommendations and the associated level of evidence.
7. Establish outcome measures that could be used to monitor the impact of the CPG/pathway implementation.
Using GRADE
The implications of a strong recommendation are:
◦For patients—most people in your situation would want the recommended course of action and only a small proportion would not; request discussion if the intervention is not offered
◦For clinicians—most patients should receive the recommended course of action
◦For policy makers—the recommendation can be adopted as a policy in most situations.
Using GRADE
The implications of a weak recommendation are:
◦For patients—most people in your situation would want the recommended course of action, but many would not
◦For clinicians—you should recognize that different choices will be appropriate for different patients and that you must help each patient to arrive at a management decision consistent with her or his values and preferences
◦For policy makers—policy making will require substantial debate and involvement of many stakeholders
Evaluating Guidelines using AGREE
◦Domain 1. Scope and Purpose is concerned with the overall aim of the guideline, the specific health questions, and the target population (items 1-3).
◦Domain 2. Stakeholder Involvement focuses on the extent to which the guideline was developed by the appropriate stakeholders (items 4-6).
◦Domain 3. Rigour of Development relates to the process used to gather and synthesize the evidence, formulate recommendations, and update them (items 7-14).
◦Domain 4. Clarity of Presentation deals with the language, structure, and format of the guideline (items 15-17).
◦Domain 5. Applicability pertains to the likely barriers and facilitators to implementation, and strategies to improve uptake (items 18-21).
◦Domain 6. Editorial Independence is concerned with the formulation of recommendations not being unduly biased with competing interests (items 22-23).
◦Overall assessment includes the rating of the overall quality of the guideline and whether the guideline would be recommended for use in practice.
Barriers to Implementation and Uptake of Clinical Practice Guidelines
◦Development of guidelines is a time consuming and labor intensive effort.
◦Current information/reporting systems are inadequate.
◦To succeed in implementing, there must be intense, multimodal dissemination efforts.
◦Many of the guidelines developed are not executable at the point of care. Few guidelines contain sufficient information on how to perform recommended interventions.
◦There is often no system for monitoring the impact of the guideline on current practice, no feedback mechanism, and no process for iterative refinement.
Factors for Ensuring Successful Implementation of Clinical Practice Guidelines
◦Traditional interventions were shown to be weakly effective (didactic, traditional, continuing medical education, and mailings)
◦More user-centered interventions were moderately effective (audit and feedback, especially when targeted to specific providers and delivered by peers or opinion leaders)
◦Relatively strong interventions included reminder systems, academic detailing, and multiple interventions
Guideline Implementability Appraisal (GLIA)
◦an appraisal instrument to provide information about a guideline’s implementability
◦used by developers to ensure that guidelines are created in a manner that facilitates their implementation or by users
◦developers have created a GLIA website, where the tool can be freely downloaded (http://gem.med.yale.edu/glia/login.htm)
Algorithms
◦Algorithms are “written guidelines to stepwise evaluation and management strategies that require observations to be made, decisions to be considered, and actions to be taken.” (Hadorn, McCormick, & Diokno, 1992)
◦Can be formulated by taking information from CPGs and arranging it in a decision-tree format.
◦Can synthesize information from diagnostic test studies and support a diagnostic process.
Clinical Pathways
◦“A cause and effect grid or framework which identifies expected measurable patient/client outcomes (or behaviors) against a timeline for a specific case-type or group.” (Zander & Hill, 1995)
◦Developed in an attempt to improve quality of care and patient satisfaction and reduce variations in practice, complications, errors, resource utilization, and costs.
◦Home-built or manufactured.
Pathway Development
Choosing Case Types
◦Using the Evidence: Pathway Development Strategies
◦Importance of basing pathways on best practice supported by solid research evidence
◦Evolution of Pathway Models
◦First generation pathways usually diagnosis, symptom-based, or focused on a specific procedure. Second generation pathways now emerging highlight activity or function with a resulting focus on education, teaching, and client outcomes rather than specific medical interventions.
Continuum Pathways
◦Enables the person receiving care to have knowledge of the entire episode of care while providers ensure that gaps between settings and services are minimized.
◦Pathway Development Teams
◦Select the specific client group for the pathway to ensure interest and enthusiasm for the task at the front line rather than solely at an administrative level.
Advantages
◦Any trends in a client’s or a group of clients’ status can be seen immediately.
◦Abnormal data recorded on a client’s record is quickly highlighted and easily retrieved.
◦Transcription and duplication of charting is eliminated resulting in significant decreases in documentation time.
◦Information that has already been recorded isn’t repeated.
◦Clients are evaluated against well-defined goals since assessments are standardized so providers evaluate and document findings consistently.
◦All providers use the same approach for each case type and begin to compare outcomes without being dependent on formalized research.
Pre-implementation Appraisal Instrument of CP
◦In deciding to implement a clinical pathway developed by others, a process of critically evaluating the clinical pathway should be undertaken.
Post-implementation Review of Process and Experience
◦Evaluation following initial implementation of a clinical pathway should collect data from multiple sources, including surveys or focus groups for users (staff surveys), consumers, families, and physicians. Chart audits should be carried out to validate information collected from surveys and provide important information regarding documentation practices.
The appraisal tool has subscales that address the following dimensions:
Dimension 1: is it an ICP?
◦Dimension 2: the ICP documentation
◦Dimension 3: the ICP development process
◦Dimension 4: the ICP implementation process
◦Dimension 5: maintenance of the ICP
◦Dimension 6: the role of the organization
