CAN-IMPLEMENT© for Guideline Adaptation and Implementation Part 1: Context

Evidence-informed practice Guideline Adaptation Guidelines in CONTEXT Evidence-informed practice Guideline Adaptation Canadian Guideline Adaptation Study Group CAN-IMPLEMENT© Methodology Resource

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)

Evidence-informed Decision-Making Adapted from DiCenso & Cullum 1998 & Haynes et al., 1996 Clinical expertise Resources Research evidence Patients’ preferences

What is EVIDENCE? (National Forum on Health, 1998). Information based on historical or scientific evaluation of a practice that is accessible to decision-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

Guideline Adaptation DEFINITIONS Clinical Practice Guidelines are systematically developed statements to assist provider and patient decisions about appropriate healthcare for specific clinical 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

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 evidence 2. an interpretive summary of the evidence 3. specific evidence-based recommendations linked to a level of evidence Note: The Canadian Partnership Against Cancer is also referred to as the “The Partnership”.

Guideline ADAPTATION A systematic process that guides local groups to identify, evaluate, adapt and use already available guidelines for their own purposes.

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

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

MODERN Guideline Agenda from Development  Validity  Rigour  Efficiency to Implementation  Utility  Applicability  Relevance  Utilization Monitoring and Accountability In terms of the bigger picture of evidence based practice and role of guidelines…….  traditional focus  current and future focus

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

The Canadian Partnership Against Cancer www.canadianpartnershipagainstcancer.ca

The Canadian Partnership Against Cancer www.canadianpartnershipagainstcancer.ca

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

The ADAPTE Collaboration www.adapte.org

The Partnership Guideline Adaptation Study (2007-2011)

Case Series Characteristics: Guideline Title Distress Management (Pilot Case) (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 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 Regional

Observations: 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. 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.

Observations: Nature of topic and health questions 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 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

Observations: 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

Observations: activity patterns 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 Lengthy period to complete Search and Screen: defining/refining and redefining health questions – looping back to the question multiple searches, iterative Multiple, concurrent activities across several steps and tasks

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.

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

The CAN-IMPLEMENT© Process Knowledge to Action Framework 3 PHASE Methodology incorporating: Implementation perspective Facilitation Project management Resource: Guide Library Science Supplement Toolkit

Knowledge to Action … a complex journey!

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.

3 Phase Methodology PHASE 1 Identification and Clarification of Issue/Problem PHASE 2 Solution Building PHASE 3 Implementation, Evaluation and Sustainability