Systematic Review, Synthesis, & Clinical Practice Guidelines

Questions to Ask in a Critical Appraisal Why was the study done? What is the sample size? Are measurements reliable and valid? How were the data analyzed? Did any untoward event happen during the study? How do the findings fit with previous research? What does this mean for practice?

Appraising Systematic Reviews Systematic reviews - compilation of similar studies that address a specific clinical question Not the same as a literature review or narrative review Process used to conduct review should be explicit Detailed description Databases accessed Search strategies Search terms Clinicians should be able to clearly see which studies were included and which were excluded and how selected studies were assessed

Appraising Systematic Reviews (cont’d) Should inform clinicians about how data were extracted from the individual studies Should provide an overview of the evaluation of the included studies Meta-analysis A statistical approach to synthesizing the results of two or more studies A relatively new methodology that has become a hallmark of EBP As with all methodologies, applicability must be considered

Question Tell whether the following statement is true or false. Meta-analysis results in evidence that is applicable to a larger patient population than individual studies.

Answer False Rationale: In meta-analyses, combining the results of several studies produces a larger sample size and thus greater power to accurately determine the magnitude of the effect. This does not, however, increase the size of the relevant patient population.

Synthesizing Qualitative Evidence Meta-studies Meta-summaries

Clinical Practice Guidelines (CPGs) Systematically developed statements based on the best available evidence CPGs address regional differences in the diagnosis, treatment, and management of patients Accessing and synthesizing individual pieces of evidence can be time-consuming and overwhelming CPGs are a time-effective and accessible source of evidence to guide practice

Clinical Practice Guidelines –Examples Systematic Reviews and Clinical Practice Guidelines from the National Heart, Lung and Blood Institute include: Joint National Committee guidelines on Hypertension Expert Panel 3 on Asthma, and Guidelines on managing overweight, cholesterol, and cardiovascular risk http://www.nhlbi.nih.gov/health-pro/guidelines

CPGs as Tools CPGs make finite recommendations for practice while still allowing the flexibility for situation- specific considerations Evidence-based practice guidelines (EBPGs) can help bridge the gap between published scientific evidence and clinical decision making However, the rigor of guidelines varies significantly

Question Tell whether the following statement is true or false. EBPGs are a valid guide to practice because they encompass not only research evidence, but also patient preferences and clinical expertise.

Answer False Rationale: EBPGs are based on the best available evidence, but it is the responsibility of the individual clinician to integrate patient preferences and clinical expertise into consideration when planning care.

Accessing Guidelines Googling “practice guideline” will yield numerous sources, including National Guideline Clearinghouse Centre for Health Evidence Canadian Medical Association Registered Nurses’ Association of Ontario (RNAO) The term “practice guideline” can be used as a limit to define a publication type in PubMed Guidelines International Network (G-I-N) has the world’s largest guideline library

National Guideline Clearinghouse (NGC) Developed in partnership with the American Medical Association and the American Association of Health Plans Of all the guidelines sources, the NGC contains the most descriptive information about guidelines

National Library of Medicine (NLM) Gateway Allows users to input search term that is then sent out to eight different NLM databases Health Services/Health Technology Assessment Text (HSTAT) Takes large guidelines, systematic reviews, and technology assessments and enables their texts to be searchable on the Internet

Question Which of the following online databases is the most likely source of a CPG to guide a nurse’s care? CINAHL EBSCO PubMed PsycInfo

Answer c. PubMed Rationale: PubMed can be searched for CPGs by setting publication limits on the query to “practice guideline.” The other databases, while containing a great deal of literature relevant to nursing, don’t have this option to search for CPGs only.

Finding the Right Guideline Locating and reviewing current guidelines on a particular subject is often overwhelming CPG should specify information such as: Who developed and funded it Who was on the panel How the guideline was developed What dates the literature review covered

Finding the Right Guideline (cont’d) Need to keep in mind that “one size does not fit all” Assess their application to the right person at the right time and in the right way Ask What are the guideline recommendations? Are the guideline recommendations valid? How useful are the recommendations?

Reading Guidelines Recommendations should be as unambiguous as possible Consider the developers’ values Should specify the process used to systematically search and review the evidence that underlies the guideline Evidence should be graded using a recognized format Recommendations themselves should be graded Updates are important Consider whether a particular guideline will help your patients

Evaluating Guidelines Consider Validity Reliability and reproducibility Clinical applicability Clinical flexibility Clarity Documentation Development by a multidisciplinary process Plans for review

Evaluating Guidelines (cont’d) Rapid critical appraisal (RCA) checklist – see text AGREE instrument NGC summaries

Question Tell whether the following statement is true or false. A valid, reliable, and applicable clinical practice guideline becomes a permanent component of the healthcare literature.

Answer False Rationale: Because a body of evidence is constantly growing and changing, CPGs cannot be considered static documents. Regular reviews and changes are necessary.

Developing Guidelines There is a need for a CPG that addresses a topic when: The topic is clinically important The topic is complex and requires clarity There is evidence of a gap between actual and optimal care There are no existing valid or relevant guidelines available There is evidence available to support guideline development The topic is central to healthy public policy

Developing Guidelines (cont’d) Processes and panels Both must be identified Review questions must be created Conducting the literature search and review Drafting recommendations Peer review and dissemination

Implementing CPGs Requires multifaceted and sustained interventions Practitioners’ commitment and organizational leadership are keys Use of best practice champions EBP mentors Guideline implementation must be sustained over time Context must be considered

Question Which of the following factors has the greatest bearing on the success or failure of CPG implementation? The strength of the evidence that underlies the guideline The validity of the process that was used to develop the guideline The education level of the nurses who will implement the guideline The commitment of the caregivers who will put the guideline into practice

Answer d. The commitment of the caregivers who will put the guideline into practice Rationale: While CPGs must be based on strong evidence and must be developed in a valid manner, these factors do not determine the success of their clinical implementation. Successful implementation is dependent on the commitment of practitioners to the process. Education level is not a key determinant of success.