Standardising evidence strength grading for recommendations from multiple clinical practice guidelines: a South African case study

K Grimmer,K Grimmer,S-M Van Niekerk,J M Dizon,C Wiysonge,D Ernstzen,Q Louw

doi:10.1186/s13012-018-0803-0

Abstract

BackgroundSignificant resources are required to write de novo clinical practice guidelines (CPGs). There are many freely-available CPGs internationally, for many health conditions. Developing countries rarely have the resources for de novo CPGs, and there could be efficiencies in using CPGs developed elsewhere. This paper outlines a novel process developed and tested in a resource-constrained country (South Africa) to synthesise findings from multiple international CPGs on allied health (AH) stroke rehabilitation.MethodsMethodologists, policy-makers, content experts and consumers collaborated to describe the pathway of an ‘average’ stroke patient through the South African public healthcare system and pose questions about best-practice stroke rehabilitation along this pathway. A comprehensive search identified international guidance documents published since January 2010. These were scanned for relevance to the South African AH stroke rehabilitation questions and critically appraised for methodological quality. Recommendations were extracted from guidance documents for each question. Strength of the body of evidence (SoBE) gradings underpinning recommendations were standardised, and composite recommendations were developed using qualitative synthesis. An algorithm was developed to guide assignment of overall SoBE gradings to composite recommendations.ResultsSixteen CPGs were identified, and all were included, as they answered different project questions differently. Methodological quality varied and was unrelated to currency. Seven clusters, outlining 20 composite recommendations were proposed (organise for best practice rehabilitation, operationalise strategies for best practice communication throughout the patient journey, admit to an acute hospital, refer to inpatient rehabilitation, action inpatient rehabilitation, discharge from inpatient rehabilitation and longer-term community-based rehabilitation).ConclusionThe methodological development process, tested by writing a South African AH stroke rehabilitation guideline from existing evidence sources, took 9 months. The process was efficient, collaborative, effective, rewarding and positive. Using the proposed methods, similar synthesis of existing evidence could be conducted in shorter time periods, in other resource-constrained countries, avoiding the need for expensive and time-consuming de novo CPG development.

Highlights

Significant resources are required to write de novo clinical practice guidelines (CPGs)
Four documents each came from Australia, USA and UK, and one each came from Canada, Malaysia, South Africa and New Zealand
Synthesis intent and wording from multiple recommendations that reported the evidence for one question in different ways and determine an Overall strength of the body of evidence (OSoBE) grading for a composite recommendation which summarised recommendations from multiple guidance documents, for one question

Summary

Introduction

Significant resources are required to write de novo clinical practice guidelines (CPGs). Implementing evidence-based practice, using comprehensive high quality clinical practice guidelines (CPGs), has been the subject of considerable research in high-income countries over the past three decades [5]. There are generally positive attitudes to using evidence in practice, and despite discipline-differences in competencies and scope of practice, similar reasons emerge for not doing so [7, 8]. These are lack of time, ready access to CPGs, understanding about different forms of evidence recommendations (e.g. CPGs, protocols, guidance) and knowledge about evaluating evidence quality. Barriers include disagreement with recommendations, unwillingness to change practices, peer-pressure, lack of managerial and organisational support and differences between recommendations and clinical realities [7,8,9]

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