Adapting Guidelines for Local Implementation: Fusion Cuisine or Fast Food Leftovers Eddy Lang MDCM CCFP(EM) Head Department of Emergency Medicine Senior Researcher Associate Professor Alberta Health Services University of Calgary

4 Brasiliophilia Gilberto Gil Gal Costa Caetano Veloso Feijoada Caipirinhia Tropa de Elite

Objectives 1.Should countries adapt other guidelines? 2.What changes behaviour? 3.How you might consider doing it?

World Bank Experience Guideline adaptation and implementation in Kazakhstan

A última pesquisa mostra que devemos realmente fazer algo com toda essa pesquisa

Monitor Knowledge Use Sustain Knowledge Use Evaluate Outcomes Adapt Knowledge to Local Context to Local Context Assess Barriers to Barriers to Knowledge Use Knowledge Use Select, Tailor, Select, Tailor, Implement Interventions Identify Problem Identify Problem Identify, Review, Identify, Review, Select Knowledge Select Knowledge Products/Tools Synthesis Knowledge Inquiry Tailoring Knowledge KNOWLEDGE CREATION

What are guidelines? 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)

The clinical practice guideline is based on a systematic review of evidence as demonstrated by documentation of each of the following features in the clinical practice guideline or its supporting documents.supporting documents

Not the word of Deus

What is guideline adaptation? A systematic process that guides local groups to identify, evaluate, adapt and use already available guidelines for their own purposes.

Why Adapt Guidelines? Efficiency Apply fruits of rigorous work to your setting New insight into health problems Access to evidence-based recommendations

What are the risks? Poor quality guidelines Poor evidence synthesis Biased recommendations Wrong context Wrong values and preferences GOBSAT

EBM Decision- making

Tool 2.5a Sample Work Plan

Task 4.2 Decision and Selection Options 1. ACCEPT a whole guideline and all of its recommendations After reviewing all of the assessments, the panel accepts the guideline as is. 2. REJECT a whole guideline and all of its recommendations After reviewing all of the assessments, the panel decides to reject the complete guideline. The decision will be based on how the panel weighs the assessments (e.g., poor AGREE scores, guideline is out-of-date, the recommendations do not apply to the panel’s context). 3. ACCEPT the evidence summary of the guideline After reviewing all of the assessments, the panel decides to accept the description of the evidence (or parts) but to reject the interpretation and the recommendations. 4. ACCEPT single recommendations After reviewing the recommendations from the guideline or guidelines, the panel decides which to accept and which to reject which may be from one or more guidelines. 5. MODIFY single recommendations After reviewing all of the recommendations from the guideline(s), the panel decides which are acceptable but need to be modified.

Potential Benefits I  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

Potential Benefits II  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

When was the last time you changed your practice to support evidence-based intervention and what made you do it?

“To achieve evidence-based clinical practice requires evidence-based implementation” Richard Grol

34 Link Barriers to Interventions Identified barriersSpecific interventions Lack of knowledgeInteractive education sessions Perception/reality mismatchAudit and feedback Lack of motivationIncentives/sanctions Beliefs/attitudesPeer influence/opinion leaders Systems of careProcess redesign V. Palda, 2007

Conclusões Guideline adaptation has risks and benefits If structured approach followed increases chance of success Guidance alone doesn’t change practice Consider evidence based approaches to achieve implementation

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How to evaluate guidelines for quality?

Tool 4.1b: AGREE Instrument 23 items 4 (7) point Likert Scale Overall Assessment User Guide & Manual 1. Scope & purpose (3) 2. Stakeholder involvement (4) 3. Rigour of development (7) 4. Clarity & presentation (4) 5. Applicability (3) 6. Editorial independence (2) SIX Domains

Ischemic Stroke Exercise Alteplase

Conclusions Guideline adaptation should be an intensive and rigorous process Made to optimize credibility and uptake Not without risks Adapte away

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