Clinical guidelines: Can we streamline the effort to increase the impact?

Clinical guidelines are being published around the world, with increasing regularity, for a plethora of clinical questions. Clinical guidelines potentially offer an opportunity for allied health clinicians to save themselves effort in identifying and synthesing relevant literature related to aspects of their clinical practice. Our research team has been working in clinical guideline development and review for over 10 years, and we have highlighted a number of concerns/ issues that need to be resolved before clinical guidelines can become consistently useful to any clinician, particularly those working in allied health. We would like to believe that clinicians will increasingly turning to clinical guidelines for evidence-based guidance, because they should provide a readily-accessible resource of transparently identified, critically appraised, synthesized literature relevant to particular clinical questions. However our work has found that this is not always so, and unless guideline development improves and becomes more standardized around the world, clinicians will continue to be frustrated. Despite the effort and time that often goes into guideline development, guideline recommendations may not be widely taken up and implemented into practice because of variability in guideline construction, and the potential mismatch between what guidelines provide, and what clinicians want. We highlight some of the issues that need to be resolved, possibly with international effort.

Repetition of effort: Guideline developers in different countries independently develop guidelines for the diagnosis and management of one condition, without any collaboration. Whilst guideline implementation may reflect different clinician needs, and different countries’ health cultures, the evidence base is surely the same. Thus one well-developed comprehensive guideline should be able to be adopted around the world with minimum local effort to ensure that all patients with this condition receive evidence-based care based on best available information. Take stroke care for instance. A quick Google.com search identifies clinical guidelines developed independently by major organizations around the world (for instance the Australian National Stroke Foundation www.strokefoundation.com.au endorsed by the National Health and Medical Research Foundation, Australia www.nhmrc.gov.au), Royal College of General Practitioners, Australia www.racgp.org.au, the Royal College of Physicians UK www.rcplondon.ac.uk, the Scottish Intercollegiate Guideline Network www.sign.ac.uk and the New Zealand Guideline Group www.nzgg.org.nz). They are all based on the same evidence, yet they all look different, and their recommendations use different wording.

No standard approach to guideline development: Most major guideline developers provide protocol manuals to assist in developing guidelines. These have similar core elements, such as the importance of identifying the best underpinning research evidence, and synthesising it, and setting the guideline purpose and target users. However few manuals provide clear guidance as to how to put an effective and efficient guideline team together, how to manage the guideline development workload, and how to efficiently produce a guideline that is timely, well written with end-users in mind, and meets its purpose. Consequently we find international guidelines on the one subject developed in a variety of ways, from one extreme of well-trained technical teams doing all the work with little clinical input, through to poorly trained and resourced clinicians doing all the work.

No standard protocols for guideline production and publication: Guidelines coming from different organizations around the world are constructed differently. There is no standard hierarchy of evidence or critical appraisal instrument in use, and no standard ways of identifying or synthesizing the best evidence, determining the scope, purpose and limitations of guidelines, or reporting recommendations within clinical guidelines. This means that guidelines from different parts of the world look different, report their components in different orders using different depths of information, and have differently organized background literature. This provides guideline users with a dilemma, which guideline do they believe and whose processes are best?

Evidence base: Guidelines provide a range of evidence underpinning recommendations, outlined in different ways. Some guidelines provide clear recommendations and levels of evidence (although using different nomenclatures). These provide guideline users with assurance of the degree to which they can trust the recommendations. Other guidelines do not provide evidence sources, questioning the believability of the recommendations. Where there is scant research evidence, many guidelines use consensus or expert opinion, although gathered in different ways. This may come from the expert clinical working committee, or from one knowledgeable person, or from a rigorous qualitative research approach such as a Delphi Consensus study. In allied health there are often situations where the current research base needs to be layered with clinical opinion. The more believable the clinical opinion, the more believable the resultant recommendations. Allied health guidelines need to adopt a consistent and rigorous approach to garnering clinical opinion to ensure that opportunities for bias are minimized, and that important clinical opinions are valued.

Implementation: Despite the number of guidelines which have been published, there has been very little effort to move guideline recommendations into wide practice. There is an emerging science in guideline implementation, which highlights a range of behavioural factors related to adopting new practices. To adopt a new practice requires clinicians to first understand and quantify their usual practice, recognize whether it can be improved, and then adopt a new practice based on believable evidence with the likelihood of improving patient health outcomes and/ or decreasing adverse practices.

Allied health guidelines are an emerging area of interest for many clinicians and researchers. There is the opportunity to streamline guideline development effort, so that scant resources can be used to improve health care practices around with world by diminishing duplication of effort, and using the best practices available to construct useable, believable clinical guidelines that can be readily implemented in every-day clinical practice.


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