Improving the use of research evidence in guideline development: 13. Applicability, transferability and adaptation.

Health Res Policy Syst. 2006;4:25

Authors: Schünemann HJ, Fretheim A, Oxman AD

ABSTRACT: BACKGROUND: The World Health Organization (WHO), like many other organisations around the world, has recognised the need to use more rigorous processes to ensure that health care recommendations are informed by the best available research evidence. This is the thirteenth of a series of 16 reviews that have been prepared as background for advice from the WHO Advisory Committee on Health Research to WHO on how to achieve this. OBJECTIVES: We reviewed the literature on applicability, transferability, and adaptation of guidelines. METHODS: We searched five databases for existing systematic reviews and relevant primary methodological research. We reviewed the titles of all citations and retrieved abstracts and full text articles if the citations appeared relevant to the topic. We checked the reference lists of articles relevant to the questions and used snowballing as a technique to obtain additional information. We used the definition “coming from, concerning or belonging to at least two or all nations” for the term international. Our conclusions are based on the available evidence, consideration of what WHO and other organisations are doing and logical arguments. KEY QUESTIONS AND ANSWERS: We did not identify systematic reviews addressing the key questions. We found individual studies and projects published in the peer reviewed literature and on the Internet.Should WHO develop international recommendations?* Resources for developing high quality recommendations are limited. Internationally developed recommendations can facilitate access to and pooling of resources, reduce unnecessary duplication, and involve international scientists.* Priority should be given to international health problems and problems that are important in low and middle-income countries, where these advantages are likely to be greatest.* Factors that influence the transferability of recommendations across different settings should be considered systematically and flagged, including modifying factors, important variation in needs, values, costs and the availability of resources.What should be done centrally and locally?* The preparation of systematic reviews and evidence profiles should be coordinated centrally, in collaboration with organizations that produce systematic reviews. Centrally developed evidence profiles should be adaptable to specific local circumstances.* Consideration should be given to models that involve central coordination with work being undertaken by centres located throughout the world.* While needs, availability of resources, costs, the presence of modifying factors and values need to be assessed locally, support for undertaking these assessments may be needed to make guidelines applicable.* WHO should provide local support for adapting and implementing recommendations by developing tools, building capacity, learning from international experience, and through international networks that support evidence-informed health policies, such as the Evidence-informed Policy Network (EVIPNet).How should recommendations be adapted?* WHO should provide detailed guidance for adaptation of international recommendations.* Local adaptation processes should be systematic and transparent, they should involve stakeholders, and they should report the key factors that influence decisions, including those flagged in international guidelines, and the reasons for any modifications that are made.

PMID: 17156457 [PubMed - in process]

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Improving the use of research evidence in guideline development: 14. Reporting guidelines.

Health Res Policy Syst. 2006;4:26

Authors: Oxman AD, Schünemann HJ, Fretheim A

ABSTRACT: BACKGROUND: The World Health Organization (WHO), like many other organisations around the world, has recognised the need to use more rigorous processes to ensure that health care recommendations are informed by the best available research evidence. This is the 14th of a series of 16 reviews that have been prepared as background for advice from the WHO Advisory Committee on Health Research to WHO on how to achieve this. OBJECTIVES: We reviewed the literature on reporting guidelines and recommendations. METHODS: We searched PubMed and three databases of methodological studies for existing systematic reviews and relevant methodological research. We did not conduct systematic reviews ourselves. Our conclusions are based on the available evidence, consideration of what WHO and other organisations are doing and logical arguments. KEY QUESTIONS AND ANSWERS: There is little empirical evidence that addresses these questions. Our answers are based on logical arguments and standards put forward by other groups.What standard types of recommendations or reports should WHO use?* WHO should develop standard formats for reporting recommendations to facilitate recognition and use by decision makers for whom the recommendations are intended, and to ensure that all the information needed to judge the quality of a guideline, determine its applicability and, if needed, adapt it, is reported.* WHO should develop standard formats for full systematically developed guidelines that are sponsored by WHO, rapid assessments, and guidelines that are endorsed by WHO.* All three formats should include the same information as full guidelines, indicating explicitly what the group preparing the guideline did not do, as well as the methods that were used.* These formats should be used across clinical, public health and health systems recommendations.How should recommendations be formulated and reported?* Reports should be structured, using headings that correspond to those suggested by the Conference on Guideline Standardization or similar headings.* The quality of evidence and strength of recommendations should be reported explicitly using a standard approach.* The way in which recommendations are formulated should be adapted to the specific characteristics of a specific guideline.* Urgent attention should be given to developing a template that provides decision makers with the relevant global evidence that is needed to inform a decision and offers practical methods for incorporating the context specific evidence and judgements that are needed.

PMID: 17156458 [PubMed - in process]

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Improving the use of research evidence in guideline development: 15. Disseminating and implementing guidelines.

Health Res Policy Syst. 2006;4:27

Authors: Fretheim A, Schünemann HJ, Oxman AD

ABSTRACT: BACKGROUND: The World Health Organization (WHO), like many other organisations around the world, has recognised the need to use more rigorous processes to ensure that health care recommendations are informed by the best available research evidence. This is the 15th of a series of 16 reviews that have been prepared as background for advice from the WHO Advisory Committee on Health Research to WHO on how to achieve this. OBJECTIVES: In this review we address strategies for the implementation of recommendations in health care. METHODS: We examined overviews of systematic reviews of interventions to improve health care delivery and health care systems prepared by the Cochrane Effective Practice and Organisation of Care (EPOC) group. We also conducted searches using PubMed and three databases of methodological studies for existing systematic reviews and relevant methodological research. We did not conduct systematic reviews ourselves. Our conclusions are based on the available evidence, consideration of what WHO and other organisations are doing and logical arguments. KEY QUESTIONS AND ANSWERS: What should WHO do to disseminate and facilitate the uptake of recommendations?* WHO should choose strategies to implement their guidelines from among those which have been evaluated positively in the published literature on implementation research* Because the evidence base is weak and modest to moderate effects, at best, can be anticipated, WHO should promote rigorous evaluations of implementation strategies.What should be done at headquarters, by regional offices and in countries?* Adaptation and implementation of WHO guidelines should be done locally, at the national or sub-national level.* WHO headquarters and regional offices should support the development and evaluation of implementation strategies by local authorities.

PMID: 17156459 [PubMed - in process]

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Improving the use of research evidence in guideline development: 16. Evaluation.

Health Res Policy Syst. 2006;4:28

Authors: Oxman AD, Schünemann HJ, Fretheim A

: BACKGROUND: The World Health Organization (WHO), like many other organisations around the world, has recognised the need to use more rigorous processes to ensure that health care recommendations are informed by the best available research evidence. This is the last of a series of 16 reviews that have been prepared as background for advice from the WHO Advisory Committee on Health Research to WHO on how to achieve this. OBJECTIVES: We reviewed the literature on evaluating guidelines and recommendations, including their quality, whether they are likely to be up-to-date, and their implementation. We also considered the role of guideline developers in undertaking evaluations that are needed to inform recommendations. METHODS: We searched PubMed and three databases of methodological studies for existing systematic reviews and relevant methodological research. We did not conduct systematic reviews ourselves. Our conclusions are based on the available evidence, consideration of what WHO and other organisations are doing and logical arguments. KEY QUESTIONS AND ANSWERS: Our answers to these questions were informed by a review of instruments for evaluating guidelines, several studies of the need for updating guidelines, discussions of the pros and cons of different research designs for evaluating the implementation of guidelines, and consideration of the use of uncertainties identified in systematic reviews to set research priorities.How should the quality of guidelines or recommendations be appraised?* WHO should put into place processes to ensure that both internal and external review of guidelines is undertaken routinely.* A checklist, such as the AGREE instrument, should be used.* The checklist should be adapted and tested to ensure that it is suitable to the broad range of recommendations that WHO produces, including public health and health policy recommendations, and that it includes questions about equity and other items that are particularly important for WHO guidelines.When should guidelines or recommendations be updated?* Processes should be put into place to ensure that guidelines are monitored routinely to determine if they are in need of updating.* People who are familiar with the topic, such as Cochrane review groups, should do focused, routine searches for new research that would require revision of the guideline.* Periodic review of guidelines by experts not involved in developing the guidelines should also be considered.* Consideration should be given to establishing guideline panels that are ongoing, to facilitate routine updating, with members serving fixed periods with a rotating membership.How should the impact of guidelines or recommendations be evaluated?* WHO headquarters and regional offices should support member states and those responsible for policy decisions and implementation to evaluate the impact of their decisions and actions by providing advice regarding impact assessment, practical support and coordination of efforts.* Before-after evaluations should be used cautiously and when there are important uncertainties regarding the effects of a policy or its implementation, randomised evaluations should be used when possible.What responsibility should WHO take for ensuring that important uncertainties are addressed by future research when the evidence needed to inform recommendations is lacking?* Guideline panels should routinely identify important uncertainties and research priorities. This source of potential priorities for research should be used systematically to inform priority-setting processes for global research.

PMID: 17156460 [PubMed - in process]

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Adherence to evidence-based statin guidelines reduces the risk of hospitalizations for acute myocardial infarction by 40%: a cohort study.

Eur Heart J. 2007 Jan;28(2):154-9

Authors: Penning-van Beest FJ, Termorshuizen F, Goettsch WG, Klungel OH, Kastelein JJ, Herings RM

AIMS: To investigate the ‘real world’ effectiveness of robust statin therapy, focusing on the effect of dose and early treatment discontinuation on the risk of hospitalization for acute myocardial infarction (AMI). METHODS AND RESULTS: In the PHARMO database, including among others drug-dispensing and hospital discharge records for more than two million subjects in the Netherlands, 59 094 new users of statins in the period 1 January 1991 until 31 December 2004, >/= 18 years of age were identified. In these patients, exposure to statins, both in terms of persistence and dose, was determined over the first two treatment years. To determine the risk for AMI, patients were followed from this 2-year time point until the first hospital admission for AMI, death, or end of the study period. A total of 31 557 patients (53%) discontinued statin use within 2 years; 20 883 patients (35%) were persistent users with an average equipotent dose >/= 4. A 30% reduction in risk of hospitalization for AMI with persistent statin use was observed. The protective effect increased with a higher dose (20 and 40% risk reduction with an equipotent dose /= 4, respectively). CONCLUSION: These results show that statins are suboptimally used in real life for having the maximum benefit in terms of preventing AMI.

PMID: 17158123 [PubMed - in process]

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Evidence behind the WHO Guidelines: Hospital Care for Children: Is Caffeine Useful in the Prevention of Apnoea of Prematurity?

J Trop Pediatr. 2006 Dec 10;

Authors: McCallum AD, Duke T

PMID: 17158815 [PubMed - as supplied by publisher]

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Patterns of guideline adherence and care delivery for patients with unstable angina and non-ST-segment elevation myocardial infarction (from the CRUSADE Quality Improvement Initiative).

Am J Cardiol. 2006 Dec 18;98(12A):30Q-35Q

Authors: Tricoci P, Peterson ED, Roe MT,

The Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) initiative is a prospective, rapid-cycle quality-improvement initiative that focuses on improving both the diagnostic evaluation of patients with non-ST-segment elevation (NSTE) acute coronary syndromes (ACS; defined as ischemic ST-segment changes and/or positive cardiac markers) and the use of treatments recommended by the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for management of NSTE ACS. The ultimate goal of the CRUSADE initiative is to improve the quality of care among high-risk patients with NSTE ACS. At the same time, the CRUSADE initiative provides the unique opportunity to evaluate the pattern of NSTE ACS management in a large-scale, routine practice setting in the United States. Cumulatively, the CRUSADE initiative has collected data from >165,000 patients with NSTE ACS admitted at >400 US hospitals since 2001. This article reviews the major results from the CRUSADE initiative on risk stratification, gaps in guidelines adherence, paradoxical care, and the association of guideline adherence with outcomes.

PMID: 17169628 [PubMed - indexed for MEDLINE]

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Easier, More Effective, Evidence-based Guidelines for Resuscitation: Understanding the Changes to the Australian Resuscitation Guidelines 2006.

Heart Lung Circ. 2007 Feb;16(1):2-6

Authors: Walters D

PMID: 17175196 [PubMed - in process]

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ACC/AHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery: focused update on perioperative beta-blocker therapy–a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery).

Anesth Analg. 2007 Jan;104(1):15-26

Authors: Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, , , , , , , , ,

The American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Practice Guidelines makes every effort to avoid any actual, potential, or perceived conflict of interest that might arise as a result of an industry relationship or personal interest of the writing committee. Specifically, all members of the writing committee, as well as peer reviewers of the document, were asked to provide disclosure statements of all such relationships that might be perceived as real or potential conflicts of interest. These statements are reviewed by the parent task force, reported orally to all members of the writing committee at each meeting, and updated and reviewed by the writing committee as changes occur. Please see Appendix 1 for author relationships with industry and Appendix 2 for peer reviewer relationships with industry. These guidelines attempt to define practices that meet the needs of most patients in most circumstances. These guideline recommendations reflect a consensus of expert opinion after a thorough review of the available, current scientific evidence and are intended to improve patient care. If these guidelines are used as the basis for regulatory/payer decisions, the ultimate goal is quality of care and serving the patient’s best interests. The ultimate judgment regarding care of a particular patient must be made by the healthcare provider and patient in light of all the circumstances presented by that patient.

PMID: 17179239 [PubMed - indexed for MEDLINE]

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Musings on guidelines and evidence: a pragmatic and nephrocentric view.

Perit Dial Int. 2007 Jan-Feb;27(1):31-4

Authors: Mendelssohn DC

PMID: 17179505 [PubMed - in process]

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