CAN-IMPLEMENT©for Guideline Adaptation and

Implementation

Part 1: Context

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-MakingAdapted from DiCenso & Cullum 1998 & Haynes et al., 1996

ResourcesClinicalexpertise

Researchevidence

Patients’preferences

What is EVIDENCE? (National Forum on Health, 1998).

Information based on historical or scientific evaluation of a practice that is accessible todecision-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 specificclinical 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 evidence2. an interpretive summary of the evidence3. 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

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 Cancerwww.canadianpartnershipagainstcancer.ca

The Canadian Partnership Against Cancerwww.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 Collaborationwww.adapte.org

The Partnership Guideline Adaptation Study (2007-2011)

Case 1 Case 2 Case 3 Case 4 Case 5 (Case)Guideline

Title

Distress Management(Pilot Case)

Distress Management(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

Medical/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 National National ProvincialRegional

National

Case Series Characteristics:

Observations:

1. 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.

2. 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:

3. 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

4. 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:

5. 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

1. 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

2. Lengthy period to complete Search and Screen: defining/refining and redefining health questions – looping back

to the question multiple searches, iterative

3. 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 1Identification and

Clarification of Issue/Problem

PHASE 2Solution Building

PHASE 3Implementation, Evaluation and Sustainability