1. Clinical Practice Guidelines
Research & Education Perspectives
Susan Rappolt
Department of Occupational Therapy University of Toronto

2. 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

3. 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

4. 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

5. 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)

6. 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

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

8. 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

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

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

11. 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

12. 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

13. 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.”

14. 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

15. 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

16. 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

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

18. 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

19. Experiences of Other Professions with CPGs
Physiotherapy
Nursing
Medicine

20. 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

21. Clinical Practice Guidelines?
What are the alternatives?