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

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

3. 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)

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

5. 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

6. 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

7. 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”.

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

9. 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

10. 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

11. 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

12. 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

13. The Canadian Partnership Against Cancer

14. The Canadian Partnership Against Cancer

15. 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

16. The ADAPTE Collaboration

17. The Partnership Guideline Adaptation Study (2007-2011)

18. 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

19. 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.

20. 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

21. 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

22. 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

23. 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.

24. 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

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

26. Knowledge to Action
… a complex journey!

28. 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.

29. 3 Phase Methodology PHASE 1
Identification and Clarification of Issue/Problem
PHASE 2
Solution Building
PHASE 3
Implementation, Evaluation and Sustainability