Gaining insight into the Clinical Practice Guideline development processes: Qualitative study in a workshop to implement the GRADE proposal in Spain

Alza Health Centre, Osakidetza-Basque Health Service, Avda Larratxo s/n, 20013 Donostia-San Sebastián, Spain.
BMC Health Services Research (Impact Factor: 1.71). 02/2006; 6(1):138. DOI: 10.1186/1472-6963-6-138
Source: PubMed


The GRADE method represents a new approach to grading the quality of evidence and strength of recommendations in the preparation of Clinical Practice Guidelines (CPG). In the context of a pilot study to assess the implementability of the system in Spain, we considered it relevant to gain an insight into the significance of the perceptions and attitudes expressed by the actual experts participating in the system try-out.
Qualitative research with an ethnographic approach, through non-participant observation and focus groups within the context of a consensus workshop in which 19 CPG experts participated to evaluate the GRADE proposal using 12 evidence tables taken from hypertension, asthma and arthritis CPGs. The interventions were recorded, under a guarantee of confidentiality. The transcriptions and field notes were analyzed, based on a sociological discourse analysis model, and the provisional findings were re-sent to participants in order to improve their validity.
1) Certain problems over procedure and terminology hindered the acceptance of this new method as a common reference system for the preparation of CPGs. 2) A greater closeness to clinical practice was accompanied by concerns over value judgments and subjectivity, with a demand for greater explicitness in the consensus process. 3) The type of "evidence" on which the guidelines are based, how and by whom the evidence is prepared, and what the role of the different actors should be, all constitute unresolved concerns in the CPG preparation and implementation processes. 4) The grading process is not neutral: professional background, prior experience and the degree of leadership all condition the participants' input and interactions.
The findings obtained allow the quantitative evaluation to be better interpreted and, in turn, go beyond the particularities of the GRADE method. Adaptation to the complexities of clinical practice, the need for carefully designed multi-disciplinary work and the reflexivity present in the CPG preparation process, all represent lines of debate that are necessary to improve the CPG quality in the Spanish health care sector.

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    • "More specifically, there is very little research on clinicians' perceptions and understanding of the grading systems used to rate the evidence, quality, and strength of recommendations [12,13]. In our context, a qualitative study about the GRADE system showed important difficulties in understanding it and an important level of disagreement among the participating clinicians, with and without previous experience in CPG development [14]. However, the participants had hardly any experience with the use of this grading system, which requires substantial methodological expertise and practice. "
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    • "These findings are consistent with those of [28], who found that both credibility of source and content of guidelines were related to GPs' willingness to follow prescribing guidelines over a variety of conditions. Guideline differences has also been previously reported as a factor which may contribute to both confusion and lack of guideline uptake in GPs [41]. "
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