Week 8

Question 1

Definition and purpose of clinical guidelines

Answer 1

• Developed statements that make recommendations to assist practitioner and patient decisions about appropriate health care for specific circumstances
  
  • A guideline is a document that summarizes the best available research evidence and expert consensus to guide clinical care
  • Aim to optimize patient care by recommending interventions that have prove benefits and they are usually developed by professional organizations or expert panels after reviewing the evidence
  • They are not meant to be strict rules but rather guidance to inform clinical judgement
  • Providers can deliver more consistent and effective care improving outcomes
    e.g. physiotherapists may use a guideline on stroke rehab

Question 2

Protocol

Answer 2

• More specific detailed plan that outlines procedures to follow in particular situations
  
  • Often local or institutional documents that specify ‘who does what, when and how’ in the management of a specific clinical scenario
  • Usually more rigid than guidelines and aim to ensure consistency and safety in practice
    e.g. a hospital might have a stroke rehabilitation protocol that details the step-by-step therapy activities

Question 3

Guideline

Answer 3

Provide general evidence-based recommendations, whereas protocols operationalise those recommendations into concrete procedures in a specific setting

Question 4

How guidelines support evidence-based practice in AH

Answer 4

• In EBP clinicians integrate the best available evidence with their clinical expertise and patient values
  
  • Clinical guidelines are a cornerstone of EBP as they summarise the best evidence into usable recommendations
  • Save practitioners time
  • For AH they help reduce unwarranted variation in care and improvement treatment outcomes by standardizing practices according to evidence
  • Also highlight the strength of evidence behind each recommendation, which helps practitioners understand how confident they can be in applying it
  • Following guidelines AH can justify their clinical decisions to patients and other professionals as being evidence-based and ensure a high quality of care across different practitioner settings

Question 5

Overview of the guideline development process (FDGADE)

Answer 5

1. Forming a guideline panel: Assemble a working group of experts and stakeholders (relevant professions/researchers). This diverse panel will oversee development
   
   2. Defining a scope and question: Clearly identify what health condition or topic the guideline will cover and formulate specific clinical questions (often using PICO) that the guideline will answer
   3. Gathering evidence: Conduct a systematic review to find the best available evidence for each question. May involve searching research literature appraising study quality and summarizing results
   4. Assessing quality of evidence: Evaluate how strong and reliable evidence is. Many guideline groups use the GRADE methodology (Grading recommendations Assessment, Development and Evaluation) to rate the certainty of evidence. Tools like GRADEpro software help create evidence profile tables and summarize findings
   5. Drafting Recommendations: Based on evidence the panel formulates recommendations. They consider benefits and risks of interventions, patient values, resource implications and quality of evidence. Each recommendation may be rated by strength
   6. External review: The draft guideline is published and disseminated to clinicians (through journals, websites, profession organisations) A plan for future updates is usually included
      Based on rigorous evidence appraisal and multidisciplinary consensus, which makes them trustworthy

Question 6

Appraising clinical guidelines using AGREE 2

Answer 6

• Not all guidelines are created equal, some are rigorous and unbiased and others are of lower quality
  
  • We need to know what makes a high-quality clinical guideline

Question 7

What makes a high-quality guideline

Answer 7

• Clear scope and purpose
  
  • Involvement of appropriate experts and stakeholder groups, rigorous methodology in gathering and analysing evidence
  • Clarity in presentation of recommendations
  • Consideration of how to implement the recommendations and transparency about conflicts of interest
  • Clearly state what question is addresses and who its meant for
  • Be based on up to date evidence
  • Have recommendations that are specific and unambiguous
  • Developed by a credible team with processes about minimising bias
    If a guideline lacks these elements, clinicians should be cautious about use

Question 8

Introduction to the AGREE 2 tool

Answer 8

• Appraisal of Guidelines for Research and Evaluation (2nd edition)
  
  • Internationally recognised tool for assessing the quality of clinical practice guidelines
  • Evaluate how well a guideline was developed
  • 23 items
  • Each rated on a 7 point scale
    Multiple appraisers independently score the guideline then aggregate the scores to get a sense of the guidelines strengths and weaknesses

Question 9

6 Domains of Agree
(SSCARE)

Answer 9

Scope and purpose
Stake holder involvement
Rigor of development
Clarity of presentation
Applicability
Editorial independence

Question 10

Scope and purpose

Answer 10

Evaluates the overall aim of the guideline, the specific health questions and the target population. States what its trying to accomplish and for whom

Question 11

Stakeholder investment

Answer 11

Checks whether the guideline development group includes the relevant professionals and represents the views of its intended users. Involves range of stakeholders

Question 12

Rigor of development

Answer 12

Examines methodology: how the evidence was gathered and summarised, the methods to formulate recommendations and how the guideline was updated. Top quality guideline will have systematic literature searches, clear criteria for selecting evidence, evidence tables

Question 13

Clarity of Presentation

Answer 13

Look at how clear and easily identifiable the recommendations are. Are they specific and unambiguous. Is the guideline well organised

Question 14

Applicability

Answer 14

Considers the likely barriers and facilitators to implementing the guideline in practice including resource implications. Good guidelines provide advice or tools for putting recommendations into practice and discuss potential organisations or cost issues

Question 15

Editorial independence

Answer 15

Assess whether the content is unbiased with respect to funding or conflicts of interest. A quality guideline clearly states any financial support and ensures that the guidelines recommendations are not unduly influenced by sponsors or the personal agendas of the panel members

Question 16

What do the domain and scores mean

Answer 16

Each domain receives a score. If a guideline scored high in rigour od development but low in applicability, it means its well evidenced but doesn’t help much with the implementation of advice

Question 17

Using Agree step by step: 1

Answer 17

Obtain the Guideline: Choose a clinical guideline document that you want to appraise (for instance, a published guideline on stroke rehabilitation from a professional association). Make sure you have the full text of the guideline, including any appendices where methods might be described. Also get a copy of the AGREE II instrument (available as a PDF or through the My AGREE Plus online platform:

Question 18

Using AGREE step by step 2

Answer 18

Skim the Guideline First: Do an initial read-through of the guideline to understand its scope, content, and structure. Identify sections that correspond to methodology (often an “Introduction” or “Methods” section), the recommendations themselves, and appendices like conflict of interest disclosures.

Question 19

Using AGREE step by step 3

Answer 19

Rate Each Item: Go item by item through the AGREE II instrument. For each of the 23 items, find the relevant information in the guideline and judge how well it meets the criteria. For example, Item 1 asks if the guideline’s overall objectives are specifically described – you’d check if the guideline explicitly states its purpose. Item 7 asks if a systematic literature search was done – you’d look for a methods section describing the search strategy. Use the 1–7 scale to score each item, where 1 means the criterion is barely met or not at all, and 7 means it’s fully met. It’s normal to use the full range of the scale; many items might score in the middle if partially met.

Question 20

Using AGREE step by step 4

Answer 20

Use Multiple Appraisers if Possible: If you’re working in a group (as you will in the workshop), each person should score the guideline independently first. Then you come together to discuss. If doing this alone for learning, you might compare your scoring with an example or a provided answer key. The AGREE II manual suggests multiple reviewers to improve reliability​.

Question 21

Using AGREE step by step 5

Answer 21

Calculate Domain Scores: After rating all items, organize the scores by domain. Sum the scores of items in each domain and scale it to a percentage of the maximum possible. For example, Rigour of Development has 8 items (Items 7–14); if you gave a total of 40 out of a max 56, that domain score is ~71%. This helps compare relative strengths: perhaps the guideline scored 90% on Scope and Purpose but only 50% on Editorial Independence.

Question 22

Using AGREE step by step 6

Answer 22

Overall Assessment: Lastly, give the guideline an overall quality score and decide whether you would recommend it, recommend it with modifications, or not recommend it for use. This final judgment considers all domain scores but also any particularly important issues. For instance, you might say: “Overall, I would recommend this guideline for use in practice, with the caution that its applicability is limited in low-resource settings.” The AGREE II tool has two global rating items to capture this final evaluation.

Question 23

Adapting guidelines for specific contexts

Answer 23

• Context differ due to resources, population etc
  Guideline adaptation is the process of taking an existing guideline and adapting it to better fit a particular context while maintaining its overall integrity

Question 24

Why and when is adaptation needed

Answer 24

• Resource differences: The original guideline may assume availability of certain interventions, medications etc that you don’t have
  
  • Population differences: Guidelines might be based on research in a certain population but your patients differ in age, ethnicity, comorbidity etc.
  • Setting differences: The healthcare setting can influence what’s feasible
  • Cultural and socio-economic: Health practices and patients preferences might vary across cultures.
    New evidence or updated priorities: Adapt guidelines if there newer evidence since the guideline was published

Question 25

Factors influencing guideline adaptation

Answer 25

- Healthcare infrastructure: equipment, services - Human resource: Have the professionals assumed by the guideline - Patient demographic and epidemiology: How do your patients compare to those in the guideline e.g. age, language spoken, condition, literacy - Cultural norms and values: Would any recommendation need cultural adaptation e.g. dietary recommendations - Socioeconomic: What are the costs associated, can patients afford them Policy environment: Are there local policies, legal issues or scopes of practice that affect implementing the guideline

Question 26

Steps in adapting a guideline (PADCDEF)

Answer 26

7. Planning and Setup: Form an adaptation team and identify the guideline(s) you plan to adapt. Make sure the source guideline is high-quality (use the AGREE II appraisal to confirm you’re starting from a sound guideline!). Define the scope of the adaptation – are you adapting the whole guideline or just parts of it for your needs? 8. Assess Contextual Needs: Do a thorough context assessment as described above. Document the differences and needs (e.g., list which recommendations might pose problems locally). Also check for any new evidence since the guideline was published or any local data that should be considered. 9. Decide on Adaptation Actions: For each recommendation in the source guideline, decide if you will adopt it as is, adapt it (modify it), or exclude it (if it’s not applicable at all). Most recommendations can be adopted directly if context differences are minor. For those that need changes, determine what modification is needed. For example, “Recommendation: 5 sessions of therapy per week” might be adapted to “3 sessions per week” if staffing is limited, with a note to aim for 5 when possible. Ensure any adaptation is still evidence-informed – maybe there is research on lower-frequency therapy that you can cite. 10. Consult Stakeholders: Engage other clinicians or experts in the region for feedback. If possible, involve patient advocates too. They might provide insight (e.g., “patients here often use traditional medicine alongside therapy – maybe acknowledge that in the guideline”). This step helps refine the adapted recommendations and build buy-in. 11. Draft the Adapted Guideline/Protocol: Rewrite the recommendations and supporting text as needed to reflect adaptations. Clearly indicate where you made changes from the original guideline and why (transparency is important – you should document the rationale, such as “due to lack of X equipment, we recommend Y alternative approach”). 12. External Review/Pilot Testing: If time permits, have the adapted guideline reviewed by an external expert or test it in practice with a small group. This “pilot” can reveal if the adaptations work as intended or if healthcare providers find them acceptable. Iteratively refine the document based on feedback​ 13. Finalise and Approve: Once satisfied, finalise the adapted guideline. Often, local authorities or committees will officially approve it (e.g., a hospital’s clinical governance board approves a new protocol). Implement and Monitor: Put the adapted guideline into practice and monitor outcomes. It’s wise to keep an eye on whether the adapted recommendations indeed improve care and to watch for any new evidence that might prompt future updates. Adaptation is rarely one-and-done; it should be seen as an ongoing improvement cycle.

Question 27

Applying guidelines in research and practice

Answer 27

Integrating guidelines into clinical decision making - Use recommendations to shape the treatment plan - Also tailor the plan Accommodate to patient preference

Question 28

How researchers use guidelines

Answer 28

15. Identifying Gaps in Knowledge: Good guidelines often include a section on research recommendations or note where evidence is weak or absent. For example, a speech therapy guideline might state that “there is insufficient high-quality evidence for intervention X in children under 2, and further research is needed.” A researcher could take this cue to design a study focusing on that gap. In this way, guidelines set the agenda for future research by highlighting unanswered questions or areas of low evidence. 16. Designing Research with Relevance: Researchers designing clinical trials or studies often look at guidelines to ensure their research will align with clinical needs. If guidelines emphasize an outcome as important (say, quality of life in stroke rehab), a researcher might include that outcome in their study to increase the study’s relevance for practice. Also, using standardized interventions that are recommended by guidelines can make a study more applicable. For instance, a physiotherapy researcher might test a new exercise protocol on top of guideline-based care, to see if adding something provides extra benefit – this way, they’re not comparing their intervention to an outdated or substandard care, but to current best practice. 17. Informing Systematic Reviews: Researchers doing evidence syntheses (like Cochrane reviews) might use guidelines to define scope or compare their findings with guideline recommendations. If new research evidence contradicts an existing guideline, that’s a significant finding and may prompt an update to the guideline. Translating Research into Practice (Knowledge Translation): Some researchers specialise in implementation science – taking guidelines and studying how to implement them effectively. For example, an occupational therapy researcher might study the best way to train community clinics to adopt a new autism guideline, measuring what helps or hinders uptake. Such research directly feeds back into making guidelines more implementable.

Question 29

Challenges in implementing guidelines in practice

Answer 29

- Provider Factors: Clinicians may be unaware of a guideline, not familiar with its content, or disagree with it based on their personal experience. Sometimes there’s inertia or resistance to change established routines (“we’ve always done it this other way”). To overcome this, ongoing education, mentorship, and demonstrating the benefits of the guideline can help. - Patient Factors: Patients’ preferences or adherence can affect implementation. If a guideline recommends a certain diet or exercise and patients are not willing or able to follow it, clinicians might struggle to implement it. Shared decision-making and tailoring recommendations to patient lifestyles are key enablers here. - Guideline-Related Factors: If a guideline is too long, complex, or not user-friendly, busy practitioners might not use it. Lack of clarity or conflicting recommendations between different guidelines can also be an issue. That’s why clarity and format are important; some guidelines now come with quick-reference summaries or infographics. - Resource and System Factors: Organizational support is crucial. If implementing a guideline requires more staff, equipment, or training, those resources need to be provided. In some cases, guidelines aren’t followed simply because the clinic or system can’t support the recommended care (for example, a guideline might recommend a certain number of therapy sessions that isn’t funded). Institutions can help by incorporating guidelines into protocols, checklists, or electronic medical record prompts, and by addressing resource gaps. - Social and Cultural Factors: The culture of a workplace or the larger healthcare system can either encourage evidence-based practice or not. For instance, if management prioritizes adhering to guidelines and measures quality based on it, clinicians feel more accountable to use them. Conversely, if peers or supervisors aren’t on board, an individual clinician might find it hard to stick out and follow a new guideline. Leadership, interprofessional collaboration, and policy-level support (like accreditation standards that reference guidelines) can all be enablers. Understanding these challenges is part of applying guidelines effectively. As a clinician, you might find yourself in a position to be a guideline champion – someone who promotes use of a guideline in your workplace. Knowing the potential barriers means you can strategise solutions (education sessions, adjusting workflows, etc.). On the other hand, if you encounter a barrier you can’t change (like a necessary piece of equipment isn’t available), that might prompt adaptation as discussed in the previous section.