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Literature update April 2012

A selection of guideline related literature covering the period December 2011-March 2012.

word cloud.jpgWe have more than 450 entries in the list of relevant literature on the G-I-N website. As we are updating this list regularly we encourage G-I-N members to subscribe to the feeds available on the pages: and (note: you have to be logged in to be able to do so).

We include here the editors’ pick of papers (including the abstracts by authors if available) retrieved during the period December 2011 – March 2012.

Van der Wees P, Qaseem A, Kaila M, Ollenschlaeger G, Rosenfeld R, and the Board of Trustees of the Guidelines International Network (G-I-N). Prospective systematic review registration: Perspective from the Guidelines International Network (G-I-N). Systematic Reviews 9 February 2012; 1:3. (

Clinical practice and public health guidelines are important tools for translating research findings into practice, with the aim of assisting health practitioners as well as patients and consumers in health behavior and healthcare decision making. Numerous programs for guideline development exist around the world, with growing international collaboration to improve their quality. One of the key features in developing trustworthy guidelines is that recommendations should be based on high quality systematic reviews of the best available evidence. The review process used by guideline developers to identify and grade relevant evidence for developing recommendations should be systematic, transparent, and unbiased. In this paper we provide an overview of current international developments in the field of practice guidelines and methods to develop guidelines, with a specific focus on the role of systematic reviews. The Guidelines International Network (G-I-N) aims to stimulate collaboration between guideline developers and systematic reviewers to optimize the use of available evidence in guideline development and to increase efficiency in the guideline development process. Considering the significant benefit of systematic reviews for the guideline community, the G-I-N Board of Trustees supports the PROSPERO initiative for international prospective registration of systematic reviews. G-I-N also recently launched a Data Extraction Resource (GINDER) to present and share data extracted from individual studies in a standardized template. PROSPERO and GINDER are complementary tools to enhance collaboration between guideline developers and systematic reviewers, allowing for alignment of activities and a reduction in duplication of effort.

Contandriopoulos D. Some Thoughts on the Field of KTE. Healthcare Policy. 2012 7(3):29-37 (

This paper offers a practice-oriented critical analysis of the scientific literature on knowledge transfer and exchange (KTE) derived from the results of a large-scale systematic review of knowledge exchange at the organizational and policy levels. Analysis is structured around four questions that must be answered to get a proper understanding of the KTE process and KTE intervention design and implementation, and of two core dimensions of context.

Dogherty EJ, Harrison MB, Baker C, Graham ID. Following a natural experiment of guideline adaptation and early implementation: a mixed-methods study of facilitation. Implement Sci. 2012 Feb 6;7(1):9 [Epub ahead of print]

Background: Facilitation is emerging as an important strategy in the uptake of evidence. However, it is not entirely clear from a practical perspective how facilitation occurs to help move research evidence into nursing practice. The Canadian Partnership Against Cancer, also known as the 'Partnership,' is a Pan-Canadian initiative supporting knowledge translation activity for improved care through guideline use. In this case-series study, five self-identified groups volunteered to use a systematic methodology to adapt existing clinical practice guidelines for Canadian use. With 'Partnership' support, local and external facilitators provided assistance for groups to begin the process by adapting the guidelines and planning for implementation. Methods: To gain a more comprehensive understanding of the nature of facilitation, we conducted a mixed-methods study. Specifically, we examined the role and skills of individuals actively engaged in facilitation as well as the actual facilitation activities occurring within the 'Partnership.' The study was driven by and builds upon a focused literature review published in 2010 that examined facilitation as a role and process in achieving evidence-based practice in nursing. An audit tool outlining 46 discrete facilitation activities based on results of this review was used to examine the facilitation noted in the documents (emails, meeting minutes, field notes) of three nursing-related cases participating in the 'Partnership' case-series study. To further examine the concept, six facilitators were interviewed about their practical experiences. The case-audit data were analyzed through a simple content analysis and triangulated with participant responses from the focus group interview to understand what occurred as these cases undertook guideline adaptation. Results: The analysis of the three cases revealed that almost all of the 46 discrete, practical facilitation activities from the literature were evidenced. Additionally, case documents exposed five other facilitation-related activities, and a combination of external and local facilitation was apparent. Individuals who were involved in the case or group adapting the guideline(s) also performed facilitation activities, both formally and informally, in conjunction with or in addition to appointed external and local facilitators. Conclusions: Facilitation of evidence-based practice is a multifaceted process and a team effort. Communication and relationship-building are key components. The practical aspects of facilitation explicated in this study validate what has been previously noted in the literature and expand what is known about facilitation process and activity.

Shiffman RN, Michel G, Rosenfeld RM, Davidson C. Building better guidelines with BRIDGE-Wiz: development and evaluation of a software assistant to promote clarity, transparency, and implementability. J Am Med Inform Assoc. 2012; 19(1):94-101.

Objective: To demonstrate the feasibility of capturing the knowledge required to create guideline recommendations in a systematic, structured, manner using a software assistant. Practice guidelines constitute an important modality that can reduce the delivery of inappropriate care and support the introduction of new knowledge into clinical practice. However, many guideline recommendations are vague and underspecified, lack any linkage to supporting evidence or documentation of how they were developed, and prove to be difficult to transform into systems that influence the behavior of care providers. Methods: The BRIDGE-Wiz application (Building Recommendations In a Developer's Guideline Editor) uses a wizard approach to address the questions: (1) under what circumstances? (2) who? (3) ought (with what level of obligation?) (4) to do what? (5) to whom? (6) how and why? Controlled natural language was applied to create and populate a template for recommendation statements. Results: The application was used by five national panels to develop guidelines. In general, panelists agreed that the software helped to formalize a process for authoring guideline recommendations and deemed the application usable and useful. Discussion: Use of BRIDGE-Wiz promotes clarity of recommendations by limiting verb choices, building active voice recommendations, incorporating decidability and executability checks, and limiting Boolean connectors. It enhances transparency by incorporating systematic appraisal of evidence quality, benefits, and harms. BRIDGE-Wiz promotes implementability by providing a pseudocode rule, suggesting deontic modals, and limiting the use of 'consider'. Conclusion: Users found that BRIDGE-Wiz facilitates the development of clear, transparent, and implementable guideline recommendations.

Eslava-Schmalbach J, Sandoval-Vargas G, Mosquera P. Incorporating equity into developing and implementing for evidence-based clinical practice guidelines. Revista de Salud Publica. 2011 Apr 13(2):339-51.

Clinical practice guidelines (CPG) are useful tools for clinical decision making, processes standardization and quality of care improvements. The current General Social Security and Health System (GSSHS) in Colombia is promoting the initiative of developing and implementing CPG based on evidence in order to improve efficiency and quality of care. The reduction of inequalities in health should be an objective of the GSSHS. The main propose of this analysis is to argue why it is necessary to consider the incorporation of equity considerations in the development and implementation of clinical practice guidelines based on the evidence. A series of reflections were made. Narrative description was used for showing the arguments that support the main findings. Among them are: 1. Differential effectiveness by social groups of interventions could diminish final effectiveness of CPG in the GSSHS; 2. To not consider geographical, ethnic, socioeconomic, cultural and access diversity issues within the CPG could have a potential negative impacts of the CPG; 3. Overall effectiveness of GPC could be better if equity issues are included in the quality verification checklist of the guideline questions; 4. Incorporating equity issues in the process of developing CPG could be cost effective, because improve overall effectiveness of CPG. Conclusions To include equity issues in CPG can help in achieving more equitable health outcomes. From this point of view CPG could be key tools to promote equity in care and health outcomes.

Lugtenberg M, Burgers JS, Clancy C, Westert GP, Schneider EC. Current guidelines have limited applicability to patients with comorbid conditions: a systematic analysis of evidence-based guidelines. PLoS ONE [Electronic Resource]. 2011 6(10):e25987.

Background: Guidelines traditionally focus on the diagnosis and treatment of single diseases. As almost half of the patients with a chronic disease have more than one disease, the applicability of guidelines may be limited. The aim of this study was to assess the extent that guidelines address comorbidity and to assess the supporting evidence of recommendations related to comorbidity.Methodology/Principal findings: We conducted a systematic analysis of evidence-based guidelines focusing on four highly prevalent chronic conditions with a high impact on quality of life: chronic obstructive pulmonary disease, depressive disorder, diabetes mellitus type 2, and osteoarthritis. Data were abstracted from each guideline on the extent that comorbidity was addressed (general comments, specific recommendations), the type of comorbidity discussed (concordant, discordant), and the supporting evidence of the comorbidity-related recommendations (level of evidence, translation of evidence). Of the 20 guidelines, 17 (85%) addressed the issue of comorbidity and 14 (70%) provided specific recommendations on comorbidity. In general, the guidelines included few recommendations on patients with comorbidity (mean 3 recommendations per guideline, range 0 to 26). Of the 59 comorbidity-related recommendations provided, 46 (78%) addressed concordant comorbidities, 8 (14%) discordant comorbidities, and for 5 (8%) the type of comorbidity was not specified. The strength of the supporting evidence was moderate for 25% (15/59) and low for 37% (22/59) of the recommendations. In addition, for 73% (43/59) of the recommendations the evidence was not adequately translated into the guidelines. Conclusions/significance: Our study showed that the applicability of current evidence-based guidelines to patients with comorbid conditions is limited. Most guidelines do not provide explicit guidance on treatment of patients with comorbidity, particularly for discordant combinations. Guidelines should be more explicit about the applicability of their recommendations to patients with comorbidity. Future clinical trials should also include patients with the most prevalent combinations of chronic conditions.

Gould N. Guidelines across the health and social care divides: the example of the NICE-SCIE dementia guideline. [Review] International Review of Psychiatry. 2011 Aug 23(4):365-70.

Increasingly, mental health services are delivered through multidisciplinary teams and settings. This creates particular challenges for the development of evidence-based practice guidelines when different professional groups represented within teams might have different traditions and cultures in relation to what counts as 'evidence', and how that might be synthesized to produce guidance that supports best practice across professional divides. These challenges are explored in relation to integration between health and social care services, where social work in particular has traditionally expressed scepticism about guideline development where it does not incorporate knowledge drawn from qualitative research and perspectives of stakeholders such as service users and carers. This article takes the NICE-SCIE guideline on dementia care as an exemplar of how an integrated process of guideline development can deliver guidance for best practice across integrated mental health services. Finally, some of the issues still facing inter-professional guideline development are considered, and pointers given to eclectic approaches that are beginning to emerge from within social work.

Hopthrow T, Feder G, Michie S. The role of group decision making processes in the creation of clinical guidelines. [Review] International Review of Psychiatry. 2011 Aug 23(4):358-64

Guideline development groups are an integral part of evidence-based healthcare and will remain so for the foreseeable future. There is a need for the efficient production of high-quality guidelines both to ensure high standards of care and to conserve resources. Social psychological research on group processes provides valuable information that can be applied to studying the functioning of guideline development groups, including the methods they use to develop recommendations. This article describes four key concepts in the group process literature: information sharing, systematic processing, group development, and group potential productivity. We evaluate their importance for guideline development groups and conclude with methodological suggestions for the study of these complex processes.

Bloemendal E, Weenink JW, Harmsen M, Mistiaen P. [Adherence to Dutch clinical guidelines: a systematic review] Naleving van Nederlandse richtlijnen: een systematische review. 2011 (

Background: Guidelines are important resources for healthcare professionals (and patients) in choosing effective and efficient therapies or interventions. In the Netherlands, the Health Care Insurance Board (CVZ) wanted to understand to what degree Dutch guidelines are efficiently utilized in different areas of Dutch health care. More specifically, they wanted an answer to the following questions: 1. To what extent do healthcare professionals adhere to Dutch guidelines?, 2. What factors play a role in (not) adhering to guideline recommendations?, 3. To what level does adherence to guidelines result in health benefits in patients, and to a more efficient health care system? Methods: We conducted a systematic literature review, for which we searched four international databases, two Dutch databases, websites of health professional associations, and websites of research institutes. Publication date was limited to the years 2000-2011. Two researchers independently selected the found references on predefined inclusion criteria; first on title and abstract, and later on the full text. Methodological quality of the remained references was evaluated using the Cochrane EPOC criteria. Relevant data were extracted from the included studies. Results: The search resulted in 8677 unique references, of which 100 documents (91 studies) were included after the two inclusion rounds. For the greater part these were observational studies, and most studies concerned guidelines for physicians. Studies showed a large variation in adherence to guidelines. In one study, for example, 38% of patients with anxiety or depression in primary care received healthcare in accordance with guidelines, whilst in another study 94% of breast cancer patients received ultrasonography conform guidelines. Apart from variance in rates, the method of measuring adherence varied widely across studies. Therefore it is difficult to compare adherence rates from different studies, and it limited us in providing a general statement about guideline adherence in the Netherlands. The included studies identified a range of influential factors associated with guideline adherence. Factors for which there is a moderate indication that they are positively related with adherence are: a positive attitude of health professionals towards guidelines, more knowledge of health professionals on the content of the guidelines, more educated health professionals, expectation of health professionals that guideline adherence results in improved patient outcomes, experienced peer pressure to use guidelines, practical usefulness of the guideline, high level of evidence of guideline recommendations, a form of automated support in using the guideline and combined methods of implementing the guideline. Furthermore, numerous studies associated patient characteristics with adherence. Although it was not always consistent in whether these characteristics had a positive or negative influence, it seems that a higher level of morbidity, higher age and presence of comorbidity are reasons for not adhering to guideline recommendations. Thirteen studies investigated the effect of guideline adherence on patient outcomes, of which a small majority showed a positive effect. No studies reported a negative effect. Seven studies investigated the influence of guideline adherence on costs, but none showed a clear association. Conclusion and discussion: Adherence to Dutch guidelines varies widely. Unfortunately, due to differences in methods of measuring and reporting adherence, we cannot provide a general statement about guideline adherence in the Netherlands. We found several factors that contribute to the use of guidelines in practice. These factors concern characteristics of the guideline itself, target population, organizational systems and implementation methods. The Health Care Insurance Board (CVZ) could take these factors into account for guideline implementation, possibly resulting in better adherence. Patient characteristics, such as degree of morbidity, age and co morbidity, seem to be associated with deviating from the guidelines. There is a limited number of studies that investigated whether higher guideline adherence results in better patient outcomes. Further research is needed to examine whether investments in guideline development and implementation lead to more efficient patient care in the long run.


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