can-implement © for guideline adaptation and implementation part 1: context
TRANSCRIPT
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CAN-IMPLEMENT©for Guideline Adaptation and
Implementation
Part 1: Context
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Guidelines in CONTEXT
Evidence-informed practice Guideline Adaptation Canadian Guideline Adaptation Study Group CAN-IMPLEMENT©
Methodology Resource
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Evidence-informed Practice
“The conscientious, explicit, and judicious use
of current best evidence in making decisions
about the care of individual patients and
involves integrating individual clinical expertise
with the best available external evidence from systematic research.” (Sackett, 1996)
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Evidence-informed Decision-MakingAdapted from DiCenso & Cullum 1998 & Haynes et al., 1996
ResourcesClinicalexpertise
Researchevidence
Patients’preferences
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What is EVIDENCE? (National Forum on Health, 1998).
Information based on historical or scientific evaluation of a practice that is accessible todecision-makers in the health care system.
Types of evidence include: experimental (randomized clinical trials, meta-
analysis, and analytic studies) non experimental (quasi-experimental, observational) historical expert opinion (consensus, commission reports) experiential
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Guideline Adaptation DEFINITIONS
Clinical Practice Guidelines are systematically
developed statements to assist provider and patient
decisions about appropriate healthcare for specificclinical circumstances. (Field & Lohr, 1990)
Their purpose is to make explicit recommendations
with a definite intent to influence what clinicians do.(Hayward et al, 1995)
► Explicit links between the recommendations & scientific evidence
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Being clear about what is a Guideline
Guidelines about clinical oncology practice or about cancer program planning or policy are defined by the(Canadian Partnership Against Cancer)* Guidelines Action Group as “cancer control guidelines”. Traditional cancer control guidelines consist of 3 elements:
1. synthesis of the body of scientific/research evidence2. an interpretive summary of the evidence3. specific evidence-based recommendations linked to a
level of evidence
Note: The Canadian Partnership Against Cancer is also referred to as the “The Partnership”.
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Guideline ADAPTATION
A systematic process that guides local
groups to identify, evaluate, adapt and use
already available guidelines for their own
purposes.
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Guideline ADAPTATION
An alternative to de novo development which requires extensive search and synthesis of primary research data
Reduces duplication of effort while maintaining the validity of recommendations
Encourages participative approach involving key stakeholders to foster local ownership of recommendations and promote utilization
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Guideline ADAPTATION
Ensures consideration of (regional and local) contextual factors to ensure relevance for practice and improve uptake by targeted users
Increases knowledge and commitment to evidence-based principles by using reliable methods to ensure quality and validity
Promotes explicitness and transparency in documenting recommendations
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MODERN Guideline Agenda
from Development Validity Rigour Efficiency
to Implementation Utility Applicability Relevance Utilization Monitoring and Accountability
traditional focus current and future focus
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CHALLENGES for the “Guideline Enterprise”
Ensure timely transfer of new research knowledge into practice
Produce high quality guidelines
Keep guidelines up-to-date
Work with limited resources
Foster local relevance and ownership of guidelines
Improve effective implementation and use of guidelines
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The Canadian Partnership Against Cancerwww.canadianpartnershipagainstcancer.ca
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The Canadian Partnership Against Cancerwww.canadianpartnershipagainstcancer.ca
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The Partnership’s Guideline Adaptation Initiative Project Team
Action Group CHAIR George Browman, Victoria
PROGRAM DIRECTOR Louise Zitzelsberger, The Partnership Office, Ottawa
PROJECT LEAD
PROJECT ADVISOR
Margaret Harrison, Queen’s University
Ian Graham, CIHR, University of Ottawa
PROJECT COORDINATORS Joan van den Hoek and Valerie Angus, Queen’s University
PROJECT ASSISTANTS Victoria Donaldson and Elizabeth Dogherty, Queen’s University
DATA MANAGER Meg Carley; The Partnership Office, Ottawa
LIBRARY SCIENCE Amanda Ross-White, Queen’s University
Patricia Oakley, CISTI
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The ADAPTE Collaborationwww.adapte.org
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The Partnership Guideline Adaptation Study (2007-2011)
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Case 1 Case 2 Case 3 Case 4 Case 5 (Case)Guideline
Title
Distress Management(Pilot Case)
Distress Management(Assessment)
Platelet Transfusion
Symptom Triage and Management Remote Support
Breast Skin Care/Wound Management
Management of Painful Bone Metastases
Focus Supportive Care: Diagnosis, referral and management of distress in adult cancer patient
Supportive Care/ Psychosocial support:
Management of distress in adult oncology patient with focus on assessment
Medical/
Treatment: Establishing platelet transfusion thresholds for pediatric population
Supportive Care Symptom Management: Knowledge translation related to ‘best practices’ for remote support in symptom assessment, triage and management for adult patients undergoing cancer radiotherapy and chemotherapy treatments
Supportive Care: Skin Care and Wound Management for patients receiving radiotherapy for breast cancer
Medical/Supportive Care: Pharmaceutical, radiotherapy and surgical approaches to management of painful bone metastases
Target Users
Multi-disciplinary – primarily front-line caregivers
Multi-disciplinary – primarily specialist services
Oncologists, Hematologists
Oncology nurses managing patient symptoms in a home healthcare setting or other environments
Front line caregivers
Oncologists, Pharmacists, Surgeons
Scope Provincial National National National ProvincialRegional
National
Case Series Characteristics:
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Observations:
1. All Study groups found the ADAPTE manual and toolkit useful and appreciated having a good structure to follow but wanted more direction for certain tasks, e.g. refining health questions, defining search strategy, managing qualitative evidence, preparing recommendations matrix.
2. Study groups relatively new to guideline development requested methodological consultation and facilitation support at the outset and for key steps and tasks, e.g.
orientation, refining health questions, defining and executing search strategy, managing qualitative evidence, preparing recommendations matrix , reaching consensus.
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Observations:
3. Guideline adaptation is not an episodic activity but part of a continuum; groups requested further direction/support in planning implementation, evaluation of adherence and outcomes of implementation
4. Timeline may not be reduced with adaptation vs. de novo development. Important factors:
Nature of topic and health questions Availability of guidelines Panel expertise, access to resources
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Observations:
5. Opportunities to expand and reformulate resources:
add project/document management and administrative guidance and materials
improve indexing and integration of Tools/Manual
Include algorithms/progress checks to ensure key decisions are addressed and documented
enable electronic/interactive formats and web access for all tools; provide access to collaborative software
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Observations: activity patterns
1. Pre-adaptation Call to Action Phase: 4-6 months to define mandate, identify and engage key stakeholders, determine and locate resources; especially true for new pan-Canadian project teams
2. Lengthy period to complete Search and Screen: defining/refining and redefining health questions – looping back
to the question multiple searches, iterative
3. Multiple, concurrent activities across several steps and tasks
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Observations: Facilitation
“ a valuable and critical process of interactive problem-solving and support, which occurs in the context of a recognized need for improvement and a supportive interpersonal relationship” (Stetler et al., 2006)
Type and level of support varied in each case, but a few common difficulties were encountered:
Refining health questions Literature search & review AGREE process Achieving consensus Recommendations matrix
Facilitation was considered an important and valued process and a key factor in continuing to drive many of the projects forward.
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Key Points
Adaptation fits within a knowledge to action framework as part of a continuum to evidence-based practice
Need to organize the adaptation process in bigger “conceptual chunks” linked to implementation, i.e. see it within a bigger framework of practice
For those thinking implementation, guideline adaptation marks the start of the process, is means to an end vs. the end itself
Paradox: process is too complex, yet not detailed enough; different perspective between target users and professional developers
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The CAN-IMPLEMENT© Process
Knowledge to Action Framework 3 PHASE Methodology incorporating:
Implementation perspective Facilitation Project management
Resource: Guide Library Science Supplement Toolkit
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Knowledge to Action
… a complex journey!
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What do we mean by “the Methodology”?
Activities related to the methodology are typically understood as the more technical elements, e.g.
Systematic reviews; Literature searches Evidence appraisals/Levels of Evidence; AGREEII instrument;
AMSTAR, GRADE Recommendations Matrices
In CAN-IMPLEMENT©, the guideline adaptation and implementation “methodology” refers to all the steps and tasks in the process. Completion of the planning elements in PHASE 1: Steps 1 and 2 , for example, are especially important to a successful outcome.
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3 Phase Methodology
PHASE 1Identification and
Clarification of Issue/Problem
PHASE 2Solution Building
PHASE 3Implementation, Evaluation and Sustainability
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