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Clinical Practice Guidelines and All That Jazz

It is now recognized that health care should be underpinned by key quality dimensions such as safety, effectiveness, patient-centeredness, timeliness, efficiency and equity. One way of operationalizing these requirements in health care is through evidence based practice (EBP). Evidence based practice is defined by Sackett and colleagues as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. In its true sense, EBP requires clinicians to convert a clinical problem into an answerable review question, search the literature, critically appraise literature findings, synthesize findings from the literature, implement it in clinical practice and finally evaluate the outcomes of integrating evidence into practice. However, in practice though, operationalizing these steps is met with numerous barriers. One of the significant barriers is the availability of time and resources to identify, appraise, and synthesize research evidence, which could then inform clinical practice.

To overcome these barriers, clinical practice guidelines (CPG) are now common place in clinical practice. Clinical practice guidelines are systematically developed statements to assist clinicians and patients decision making about appropriate health care for specific clinical circumstances. A CPG can inform a number of decisions in health care including assessment, diagnosis, management and treatment of specific conditions. It is important to point out that currently a number of different terminologies are used to describe summaries or statements of best available evidence. These include (but are not limited to) evidence statements, clinical recommendations, guidelines, care protocols, clinical or care pathways, care decision making processes, evidence based patient journeys, algorithms, flow charts and clinical points. While some claim that these individual terms denote specific products, and as such each is unique, others claim they are all essentially the same. Currently there is little clarity on what is the most appropriate nomenclature to denote evidence summaries.

For now, let’s put aside the nomenclature confusion and focus on clinical practice guidelines in allied health. How are CPGs actually developed? Is there a standardized process or is it fair game for anyone? Clinical practice guideline development in the allied health field is in its infancy. It is a complex and time consuming process and the level of skills and resources required should not be underestimated. Many inexperienced developers, usually clinicians who are responding to a call to integrate research evidence into clinical practice, can be lured into a false sense of security and not understand the complexity of the CPG development process.

Planning is the key element for developing CPGs. From a pragmatic perspective, there are five key steps to the planning process for CPG development. They are "why, what, when, who and how” and we will discuss each of these steps in more detail. It is important to note that planning is a circular process, so adjustments may be needed along the way, as you proceed through these steps. A word of caution - without appropriate planning including the consideration of potential risks, a CPG may not achieve its intended outcome.

  1. WHY develop the CPG: This is the cornerstone to CPG development and without a clear understanding of why this CPG is being developed, the process will not be efficient or effective. Some common reasons for developing CPGs include: updating an existing CPG with current evidence, a new field of practice has emerged, poor practices or to address conflicting practices. The WHY also includes having a clear purpose and scope for the CPG, to ensure that the CPG does not become unwieldy and irrelevant. Finally, the target end-users of the CPG need to be clearly identified and understood. Having an understanding of what they would want and how they would use it is essential to ensuring its relevancy.
  2. WHAT is being developed: This considers aspects such as the product you are producing (i.e. are you producing a suite of products from complete CPGs, to consumer posters and pamphlets, or just a CPG document), and is the document to be approved/ratified by the relevant professional association or an important organization (in which case there may be specific requirements and processes that you have to follow). Many guideline developers seek this ratification to enhance the creditability of CPGs and to ensure CPGs wider implementation across profession(s). Again the WHAT needs to reflect the needs of the target end-users. For example a busy clinician is unlikely to be able to wade through 100s of pages in a CPG during a consultation, so a summary desktop chart may be needed.
  3. WHEN is the guideline to be developed: It needs to be understood that CPG development is a complex task, involving multiple steps. Thus, planning is critical to minimize slippages. For example, if team members’ unavailability is not taken into account, this will have roll on effects as most tasks are inter-linked with each other. In these instances, delays in producing the draft chapters (because of team member unavailability), may affect the timing of public consultation, as there is no draft document available. This is then likely to impact on other tasks dependant on the outcome of these activities. Developing a detailed timeline with all associated tasks, no matter how minor is essential, as well as considering the availability of all your resources.
  4. WHO should develop the guideline: There are commonly three approaches to structuring a guideline development team. A team comprising of only clinical content experts, a team comprising of only technical writers who are not content experts, or utilizing a combination of the two groups. There are advantages and disadvantages associated with each team structure. Your selection will depend on the individual circumstances of the guideline you are developing and the required skill mix. You need to ensure though that you have the right skill mix for the right amount of time. This can be achieved through having a good understanding of how the development is to occur.
  5. HOW to develop the guidelines: This is how to best utilize and allocate the resources that you have available to ensure that all steps in developing the guideline will be efficiently and effectively undertaken. Communication becomes a critical element of the HOW, as well as the establishment of processes to ensure that the development of the guidelines ‘stays on track’, and to minimize any identified risks to the process. Although guideline development is a team effort, it is important that there is one person who is responsible for overseeing the whole process, to ensure its efficiency.

In allied health, as we move towards implementing evidence in clinical practice, using CPGs as a key tool to achieve this, as clinicians, we need to be informed consumers of CPGs. Integral to this is a sound understanding of the processes underpinning CPG development. Further information on CPG development, and other aspects of CPGs, can be found in the International Centre for Allied Health Evidence’s newly released textbook, Practical tips for using and developing guidelines: An allied health primer. Specifically this book aims to assist allied health clinicians to: find and critically appraise guidelines, adapt currently available guidelines to their own area of practice, understand the processes of guideline development and identify elements of allied health guideline construction that could be improved.

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