Clinical Practice Guidelines Research & Education Perspectives Susan Rappolt Department of Occupational Therapy University of Toronto s.rappolt@utoronto.ca

Clinical Practice Guidelines Definition: A systematically developed statement designed to assist clinician and patient decisions about appropriate health care for specific clinical circumstances Field and Lohr, 1990 CPGs recommend course of action

When written carefully, CPGs can offer guidance on treatment options based upon the established effectiveness of available therapeutic options (including no treatment), a patient’s individual clinical situation, minimization of harm, and cost. Green & Piehl, 2003

Evidence-Based Practice Evidence-based practice (EBP) is like a toolbox of methods available to the occupational therapy practitioner to aid clinical reasoning. The toolbox consists primarily of methods designed to integrate current and best evidence from research studies into the clinical reasoning process. Tickle-Degnen, 2000

The EBP “Toolbox” Expert opinion, consensus panels Research papers (CAPS - critically appraised papers) Systematic Reviews (CATS: critically appraised topics) Clinical practice guidelines (short-cuts to evidence)

Decision Making in Client-Centred Practices Client evidence Research evidence Professional Expertise: Knowledge of the context and resources Knowledge of own scope and skill level

Accepted View of Professional Expertise in Client-Centred Evidence-Based Practice

in Client-Centred Evidence-Based Practice Re-thinking Professional Expertise in Client-Centred Evidence-Based Practice The Role of Professional Expertise in CCEP C L I E N T Stage 1 Client Evidence 1. Gather and appraise client evidence 2. Identify occupational performance issues   Collaborative Role Professional & Client Stage 2 Research Evidence 1. Identify problem and research question 2. Gather relevant evidence 3. Appraise quality of evidence   Stage 3 Integration of Evidence 1. Establish applicability and appropriateness 2. Determine method 3. Identify evaluation criteria 4. Anticipate outcomes Professional Role Clinical Expertise Stage 4 Decision-Making 1. Discuss evidence with client 2. Develop collaborative plans for intervention   Collaborative Role Professional & Client Stage 5 Enablement and Evaluation 1. Further assessments as needed 2. Undertake processes for enablement 3. Evaluate outcomes   Collaborative Role Professional & Client O U T C M E Professional Role Research Expertise SPECIFIC CONTEXT OF PRACTICE

Revised Role of Professional Expertise in Client-Centred Evidence-Based Practice Clinical Practice Guidelines

Functions of CPGs For the Client: Transparent treatment plans for informed collaborative decision-making Fosters best possible clinical practice Promotes best possible clinical outcomes

Functions of CPGs For the Therapist: Guide for practice Efficient short-cut to evidence Enhances validity of treatment approach for clients, regulators and payers Enhances credibility for marketing services

Functions of CPGs For the Profession: Formalizes a general practice process within a clinical domain Facilitates development of knowledge repertoire of profession Provides credibility in negotiations with payers

Functions of CPGs Legal functions: CPGs could be used with expert testimony to aid in determining the standard of care Expert testimony is used to determine the applicability of the CPG to the particular case. McDonagh, Lavis & Sharpe, 2002 “Deference to a guideline as the “the standard” will not obviate the need for individuals to interpret its applicability or reasonableness. “ “Expert opinion plus a relevant clinical practice guideline (especially from a national organization) form a difficult standard to rebut.”

Functions of CPGs For Payers: Serve as guidelines for when to refer to OT Provide justification for allocation of resources Can be misused to constrain service utilization and control costs

Functions of CPGs For Researchers: CPGs provide a common protocol for studies of treatment effectiveness in improving client outcomes Results of studies of treatment effectiveness are used to validate or revise CPGs

How are CPGs developed? Determine topic Assemble stakeholders Assemble and evaluate evidence Collaboratively produce guidelines Disseminate guidelines (full, abridged and consumer versions) Evaluate the impact of the guidelines Revise guideline as needed

How to Evaluate a CPG: Defined scope and purpose Stakeholder involvement Rigorous development Clear and well presented Applicability Editorial independence

Effectiveness of CPGs in Improving Clinical Outcomes: “…some evidence that guideline-driven care can be effective in changing the process and outcome of care provided by professions allied to medicine.” Thomas, Cullum, McColl, Rousseau, Soutter & Steen, 2005

Experiences of Other Professions with CPGs Physiotherapy Nursing Medicine

Experiences of Other OT Organizations with CPGs American Association of Occupational Therapists (AOTA) National Association of Rheumatology Occupational Therapists (NAROT) CAOT: Guidelines for Client-Centred Practice

Clinical Practice Guidelines? What are the alternatives?