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

Abstract

Key points• Clinical practice guidelines can be adapted to local circumstances and settings to avoid duplication of efforts and optimize use of resources.• The ADAPTE process is an approach to adapting guidelines to local contexts through the explicit participation of relevant decision-makers.• Assessing barriers to and facilitators of the use of knowledge is closely linked to the adaptation and uptake of the evidence. Review CMAJ • FEBRUARY 9, 2010 • 182(2) E79evidence-based practice guidelines have become mandatory for the care of patients with cancer in France. 14 For many regions and territorial jurisdictions, de novo development of guidelines is not feasible because of lack of time, expertise and resources, and thus taking advantage of existing highquality guidelines is sensible. [15][16][17] Adaptation of existing high-quality guidelines for local use is an approach with the potential to reduce duplication of effort and enhance applicability. National guidelines often lack details on applicability and description of the changes in the organization of care required to apply the recommendations. 18 Adaptation of evidence may promote local uptake of evidence through a sense of ownership by the end-users who are engaged in this process. However, customizing a guideline to local conditions could weaken the integrity of the evidence base. We outline a systematic, participatory approach for evaluating and adapting available guidelines to a local context of use while maintaining the quality and validity of the guideline. Whether evidence is provided in the format of syntheses of knowledge, patient decision aids or clinical practice guidelines, end-users must consider if or how it could be adapted to the local context and the same principles can be applied to ensure these factors are considered before implementation of the evidence.To illustrate how to adapt guidelines, we will use a recent study that was performed to improve community care of individuals living with venous ulcers of the leg. 10,13 Regional managers of home care were concerned about costs of supplies, amount of nursing time, and frequency of visiting for clients with ulcers of the leg. A regional task force was developed to review existing practice guidelines to help guide the care plan. The task force identified that many of these guidelines were from international bodies and would require adaptation to the local context. How are guidelines adapted for local use?Existing guidelines can be evaluated and customized to fit local circumstances through an active, systematic and participatory process. This process must preserve the integrity of the evidence-based recommendations when differences in organizational, regional or cultural circumstances may legitimately require important variations in recommendations. 8,9,[14][15][16]19 In adapting a guideline, consideration is given to local evidence, such as specific health questions relevant to a local context of use; to specific needs, priorities, legislation, policies and resources; to scopes of practic...

Evidence-based scientific exercise guidelines for adults with spinal cord injury: an update and a new guideline

“…Based on the best available scientific evidence from studies involving adults with SCI, what is the type of exercise, and the minimum frequency, intensity, and durations (FITT principle) of exercise, needed to elicit fitness and cardiometabolic health benefits for adults with SCI? The guidelines are positioned as scientific guidelines meaning that they are wholly evidence-based and have not undergone knowledge translation or patient-public-involvement (PPI) processes [36,37] to refine language or presentation for non-scientific audiences. Nevertheless, the guidelines are meant to be applicable to exercise performed in rehabilitation settings, fitness centers, and people's homes.…”

“…The health guideline tended to have higher scores on items pertaining to clarity of instructions. These data will help to inform translation of these scientific guidelines into guidelines for use in clinical and community settings [36].…”

“…The present guidelines are rigorously linked to an underlying evidence base and have not been reworded or simplified for endusers. The panel acknowledged that a comprehensive, community-engaged strategy is needed for translating the scientific guidelines into clinical and community practice guidelines [36] that can be easily understood by SCI consumers and the people who support them.…”

“…The guidelines must undergo a rigorous and systematic consumer engagement/patient-public involvement (PPI) [36,37] before widespread dissemination. This process will involve engaging with SCI consumers and other key stakeholder groups (see "Target users of the guidelines") to determine how to optimally present/message the scientific guidelines to these groups, and the types of informational resources needed to facilitate guideline uptake and implementation (e.g., resources that explain the concept of exercise intensity, or provide sample workout plans for implementing both exercise guidelines into a single workout plan).…”

“…Our preliminary survey of SCI consumers and SCI clinicians can help inform this process (Table 4), which is already underway in Canada and the UK. Subsequent papers will be published detailing these activities in order to provide a template for groups in other countries to undertake their own consumer-engagement/PPI processes to make the guidelines relevant to local contexts [36] Panel members emphasized that processes to make the guidelines relevant to particular environments or settings must not alter the scientific integrity of the guidelines. Specifically, changes cannot be made to the exercise dose or to the population targeted by the guidelines.…”