Using Guidelines: The Need for Adaptation

Ian D Graham, PhD, FCAHS

December 10, 2012E-GAPPS

Disclosures• No relationships with industry• Co-editor of Knowledge Translation in Health Care

(2009)- all royalties go to students• Co-creator of K2A Cycle, Ottawa Model of Research

Use, Practice Guideline Evaluation and Adaptation Cycle

• Founding member of ADAPTE Collaboration• Advisor to CAN-IMPLEMENT• Acknowledgements: CAN-IMPLEMENT for

permission to use some of their slides

Session will cover

• What is guideline adaptation

• Why the need for adaptation

• Some approaches to adaptation

The Challenge

Guideline ADAPTATION

A systematic process that guides local groups to identify, evaluate, adapt and usealready available guidelines for their ownpurposes.

Done for two major reasons, to facilitate:• guideline development• guideline implementation

Guideline ADAPTATION: Done for Development Purposes

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

Increases knowledge and commitment to evidence-based principles by using reliable methods to ensure quality and validity

Promotes explicitness and transparency in documenting recommendations

Guideline ADAPTATION: Done for Implementation Purposes

• When an existing guideline does not completely address a setting’s clinical question (adapt from 1 or multiple guidelines to create an adapted de novo guideline that addresses the clinical question)

• To prepare for implementing guideline recommendations (prioritizing recommendations, adapting language, aligning recommendation to context, anticipating and addressing implementation barriers)

Guideline ADAPTATION: Social Constructivist Theory

Participatory approach engaging key stakeholders means:

-> focusing on the clinical question of interest-> interactive problem solving-> co-creating of knowledge-> ownership of recommendations to be implemented-> ensuring consideration of contextual factors to ensure

relevance to practice in anticipation of implementation

-> increasing likelihood of implementation

First Came the Practice Guideline and

Evaluating Cycle (1999-2005)

Developed working with regional group interested in improving wound care in the community

Community of practice formed around adaptation process

Action research, participatory styleAnticipated & dealt with blocks before they

became major barriers to implementationIterative process of using external evidence &

producing local ‘evidence’ for adaptation

Practice Guidelines Evaluation and Adaptation Cycle

1. Identify a Clinical Area to Promote Best Practice

2. Establish an Interdisciplinary Guideline

Evaluation Group

3. Establish Guideline Appraisal Process

4. Search and Retrieve Guidelines

5. Guidelines Assessmenta) Qualityb) Currencyc) Content

6. Adaptation of Guidelines for Local Use

7. External Review – Practioner and Policy Maker Feedback;

Expert Peer Review

8. Finalize Local Guideline

9. Official Endorsement and Adoption of Local

Guideline

10. Scheduled Review and Revision of Local Guideline

ADAPTE Collaboration

• Merging of ADAPTE group and PGEAC group (Jan 2006) international collaboration

• Members include guideline developers, researchers, guideline implementers

• Concept, process housed with resources– 12 page manual – Detailed resource toolkit– Web resources

• ADAPTE turned over to the Guideline-International-Network

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PREPARE FOR ADAPTE PROCESS

EXTERNAL REVIEW

PLAN FOR FUTURE REVIEW AND UPDATE

PRODUCE FINAL GUIDELINE

ASSOCIATED MODULES

PHASES TASKS

DEFINE HEALTH QUESTIONS

SEARCH AND SCREEN GUIDELINES

ASSESS GUIDELINES

DECIDE AND SELECT

DRAFT GUIDELINE REPORT

Preparation

Scope and Purpose

Search and

Screen

Assessment

Decision andSelection

Customization

ExternalReview

Aftercare planning

Final Production

17

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t U

p P

has

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pta

tio

n P

ha

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Fin

ali

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tio

nPh

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PREPARE FOR ADAPTE PROCESS

EXTERNAL REVIEW

PLAN FOR FUTURE REVIEW AND UPDATE

PRODUCE FINAL GUIDELINE

ASSOCIATED MODULES

PHASES TASKS

DEFINE HEALTH QUESTIONS

SEARCH AND SCREEN GUIDELINES

ASSESS GUIDELINES

DECIDE AND SELECT

DRAFT GUIDELINE REPORT

Preparation

Scope and Purpose

Search and

Screen

Assessment

Decision andSelection

Customization

ExternalReview

Aftercare planning

Final Production

The ADAPTE Collaborationwww.adapte.org

CAN-IMPLEMENT (2007-2011)

• Canadian Partnership Against Cancer Guideline Action Group project

• 5 groups across Canada interested in guideline adaptation to facilitate use of best practice started with ADAPTE process that evolved and expanded with experiential knowledge of adaptation

• Adaptation process integrated with Knowledge to Action Cycle

CAN-IMPLEMENT 3 Phase Methodology

PHASE 1Identification

and Clarification of

Issue/Problem

PHASE 2Solution Building

PHASE 3Implementation, Evaluation and Sustainability

Key Points

For those thinking implementation, guideline adaptation marks the start of the process, is means to an end vs. the end itself

The participatory nature of adaptation fosters end-user engagement in planning for implementation (creation of community of practice around uptake of adapted guideline)

The focus on alignment of guideline recommendations with local context/evidence and interactive problem solving regarding potential barriers and solutions to potential resistance enhances ownership and implementation of the adapted guideline

Knowledge, if it does not determine action, is dead to us

Plotinus (Roman philosopher 205AD-270AD)