Adapting clinical practice guidelines to local context and assessing barriers to their use

School of Nursing, Department of Community Health and Epidemiology, Queen's University, Kingston, Ontario.
Canadian Medical Association Journal (Impact Factor: 5.96). 12/2009; 182(2):E78-84. DOI: 10.1503/cmaj.081232
Source: PubMed
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Available from: Margaret B Harrison,
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    • "Contextual influences on clinical decisions are increasingly recognized as a challenge to the translation of evidence into clinical practice, across a range of contexts [1] [2]. A range of personal, environmental, organizational, technological and group factors that act as influential elements of a complex system -contextual factors -can shape the decisions made by clinicians and vice versa [3] [4]. "
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    ABSTRACT: Rationale and aims: Contextual factors are increasingly recognized as having a significant influence on clinical-decision-making. Contextual influences however, are considered ‘less scientific’ or ‘non-clinical’ in the eyes of practicing clinicians, making these matters sensitive issues for discussion. Exploring these contextual influences, therefore, can be challenging. Methods which can circumvent this challenge are required to evaluate clinical decision making in natural settings. This paper reports on the development of an innovative research method to address this challenge of exploring contextual influences and similar sensitive and complex clinical practice issues. Method: We conducted a field research to test an interview based method which was termed as ‘Clinician Recalled Vignette (CRV) Method’. Based on reflections on the field research experience, this preliminary method was refined to develop an innovative method which is potentially capable of eliciting and addressing sensitive and complex clinical practice issues. Results: Reflections on field test data provided preliminary evidence on the usefulness of the CRV method and limitations. The method that was refined, with reference to various limitations, focused on key decision points relevant to the clinical vignettes recalled by clinicians and included a mechanism to identify how contextual factors influenced these key decision points. This innovative method was termed ‘Vignette-based Decision Point Analysis’. Conclusions: We submit that the innovative method discussed in this paper will assist other researchers in conceptualizing and conducting research projects to explore sensitive and complex clinical practice issues in natural settings.
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    • "Having a separate decision aid (Figure  2) for the site in which coronary CT angiography is routinely used in lieu of cardiac stress testing in low-risk chest pain patients introduces heterogeneity in the intervention. However, a key aspect of contemporary evidence-based medicine involves translating evidence into practice in a manner that is sensitive to local practice context [30] as well as patients’ values and preferences [31], and our decision to design two different decision aids reflects an underlying commitment to these values. In addition, a key goal of the decision aid is to generate a conversation about the evidence surrounding a management decision and, by necessity, the conversation must include the management options frequently used in that practice context to be relevant for participating clinicians. "
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    ABSTRACT: Background Chest pain is the second most common reason patients visit emergency departments (EDs) and often results in very low-risk patients being admitted for prolonged observation and advanced cardiac testing. Shared decision-making, including educating patients regarding their 45-day risk for acute coronary syndrome (ACS) and management options, might safely decrease healthcare utilization. Methods/Design This is a protocol for a multicenter practical patient-level randomized trial to compare an intervention group receiving a decision aid, Chest Pain Choice (CPC), to a control group receiving usual care. Adults presenting to five geographically and ethnically diverse EDs who are being considered for admission for observation and advanced cardiac testing will be eligible for enrollment. We will measure the effect of CPC on (1) patient knowledge regarding their 45-day risk for ACS and the available management options (primary outcome); (2) patient engagement in the decision-making process; (3) the degree of conflict patients experience related to feeling uninformed (decisional conflict); (4) patient and clinician satisfaction with the decision made; (5) the rate of major adverse cardiac events at 30 days; (6) the proportion of patients admitted for advanced cardiac testing; and (7) healthcare utilization. To assess these outcomes, we will administer patient and clinician surveys immediately after each clinical encounter, obtain video recordings of the patient-clinician discussion, administer a patient healthcare utilization diary, analyze hospital billing records, review the electronic medical record, and conduct telephone follow-up. Discussion This multicenter trial will robustly assess the effectiveness of a decision aid on patient-centered outcomes, safety, and healthcare utilization in low-risk chest pain patients from a variety of geographically and ethnically diverse EDs. Trial registration NCT01969240.
    Trials 05/2014; 15(1):166. DOI:10.1186/1745-6215-15-166 · 1.73 Impact Factor
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    • "Having a strict process for guideline development will go some way to producing more consistent and high quality guidelines. It is also appropriate to have evidence-based guidelines that reflect the cultural and health care systems in a particular region [49,50]. "
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    ABSTRACT: While many women and infants have an uneventful course during the postpartum period, others experience significant morbidity. Effective postpartum care in the community can prevent short, medium and long-term consequences of unrecognised and poorly managed problems. The use of rigorously developed, evidence-based guidelines has the potential to improve patient care, impact on policy and ensure consistency of care across health sectors. This study aims to compare the scope and content, and assess the quality of clinical guidelines about routine postpartum care in primary care. PubMed, the National Guideline Clearing House, Google, Google Scholar and relevant college websites were searched for relevant guidelines. All guidelines regarding routine postpartum care published in English between 2002 and 2012 were considered and screened using explicit selection criteria. The scope and recommendations contained in the guidelines were compared and the quality of the guidelines was independently assessed by two authors using the AGREE II instrument. Six guidelines from Australia (2), the United Kingdom (UK) (3) and the United States of America (USA) (1), were included. The scope of the guidelines varied greatly. However, guideline recommendations were generally consistent except for the use of the Edinburgh Postnatal Depression Scale for mood disorder screening and the suggested time of routine visits. Some recommendations lacked evidence to support them, and levels or grades of evidence varied between guidelines. The quality of most guidelines was adequate. Of the six AGREE II domains, applicability and editorial independence scored the lowest, and scope, purpose and clarity of presentation scored the highest. Only one guideline provided comprehensive recommendations for the care of postpartum women and their infants. As well as considering the need for region specific guidelines, further research is needed to strengthen the evidence supporting recommendations made within guidelines. Further improvement in the editorial independence and applicability domains of the AGREE ll criteria would strengthen the quality of the guidelines.
    BMC Pregnancy and Childbirth 01/2014; 14(1):51. DOI:10.1186/1471-2393-14-51 · 2.19 Impact Factor
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