Guideline Development Project Research Articles

Strengthening prehospital clinical practice guideline development in South Africa: Reflections from guideline experts.

IntroductionDe novo (new) guideline development methods are well described and supported by numerous examples, including comprehensive checklists. However, alternative guideline development methods, which draw from existing up to date, high quality clinical practice guidelines instead of re-inventing the wheel, have not been adopted so readily, despite the potential efficiencies of such methods compared to de novo development. In Africa, guideline quality and rigour of development, especially for prehospital care, remains poor. This paper firstly describes the opinions of international guideline experts on the African Federation for Emergency Medicine guideline project, and secondly updates a framework for South African prehospital guideline development.MethodsWe conducted a qualitative study of expert reviews of an evidence-based guideline development project led by the African Federation for Emergency Medicine in 2016 for prehospital care in South Africa. We purposefully sampled key international and regional guideline experts from a range of organisations. Comments and voice memos, following a terms of reference guide, were thematically analysed through manual coding.ResultsA total of seven experts gave feedback. Key themes revolved around existing international clinical practice guidelines not being enough to cover context specific evidence, blurring of guideline responsibilities and output, and transparency of guideline decisions and conflicts of interest. We showcase three fit-for-purpose guideline development approaches and provide an updated alternative guideline development roadmap for low-resource settings.ConclusionIn order to create clinical practice guidelines that clinicians trust and use on a daily basis to change lives, guideline developers need rigorous yet pragmatic approaches that are responsive to end-user needs. Reflecting on the African Federation for Emergency Medicine prehospital guideline development project in 2016, this paper presents key guiding themes to strengthen guideline development in low- and middle-income countries and other low-resource settings and provides an updated hybrid guideline development approach.

Exercise Recommendations for Women with Polycystic Ovary Syndrome: Is the Evidence Enough?

In this opinion piece, we summarize, discuss implications of implementation, and critically evaluate our 2018 evidence-based guideline recommendations for exercise and physical activity in women with polycystic ovary syndrome (PCOS). We developed recommendations as part of a larger international guideline development project. The overall guideline scope and priorities were informed by extensive health professional and consumer engagement. The lifestyle guideline development group responsible for the exercise recommendations included experts in endocrinology, exercise physiology, gynecology, dietetics, and obstetrics, alongside consumers. Extensive online communications and two face-to-face meetings addressed five prioritized clinical questions related to lifestyle, including the role of exercise as therapy for women with PCOS. The guideline recommendations were formulated based on one narrative and two evidence-based reviews, before consensus voting within the guideline panel. The development process was in accordance with the Appraisal of Guidelines for Research and Evaluation (AGREE) II, and used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework to assess evidence quality, desirable and undesirable consequences, feasibility, acceptability, cost, implementation, and recommendation strength. Given the evidence for exercise as therapy in PCOS being of low quality, a consensus recommendation was made based on current exercise guidelines for the general population. Women with PCOS and clinicians are forced to adopt generic approaches when recommending exercise therapy that perpetuates clinical management with pharmacological solutions. The current status of evidence highlights the need for greater international co-operation between researchers and funding agencies to address key clinical knowledge gaps around exercise therapy in PCOS to generate evidence for appropriate, scalable, and sustainable best practice approaches.

Multinational Gout Recommendations Released

Multinational Gout Recommendations Released

P111 A Workflow Checklist for Improving Management of the Guideline Development Process

BackgroundKeeping track of progress and meeting deadlines can be difficult for organisations that simultaneously develop multiple guidelines involving multiple systematic review teams.ObjectivesTo improve planning, organising and managing of guideline development...

The use of medication to manage behaviour problems in adults with an intellectual disability: a national guideline

This article describes a national guideline for the use of medication in the management of problem behaviours in adults with an intellectual disability. As problem behaviours in this group are common and medication is often prescribed ‘off licence’, it is important that a framework is established to direct this practice. The article details a guideline development project that is of importance because it is the only national guideline in the area. It also highlights important issues in clinical practice in the field, and addresses the current evidence base on the effectiveness of psychotropic medications in the management of problem behaviours. There is a lack of good research evidence to support use of medication for problem behaviours. Where medication is used for this purpose, it should be used with a clear rationale, following a thorough assessment of the individual, and carefully monitored, and withdrawal should always be considered. People should always be given information in a way that they understand, and they should be given choices about their treatment.

A multi‐centre audit of the use of medication for the management of behavioural problems in adults with intellectual disabilities

Accessible summary Doctors prescribe people with learning disabilities medicine for a behavioural problem. The behaviours are things like hitting other people, screaming and breaking things. Doctors and nurses should give people information about the medicine that has been prescribed to them and asked whether they agree to take the medicine. Doctors who prescribe medicine for behavioural problems should write in the case notes what they have done. SummaryThe aim was to investigate prescribing practices surrounding the use of medication for the management of behavioural problems in adults with intellectual disabilities with reference to a national guideline development project. A case note review methodology was employed to explore adherence to the audit criteria that were derived from the recommendations made in the guideline. A total of 154 cases were identified as meeting the inclusion criteria. There was some variation in adherence to the examined audit criteria with some areas achieving high compliance whereas others were deemed as lacking. Such areas achieving high compliance included assessment of the behaviour, assessment of surrounding behavioural, medical, psychological/psychiatric and social issues and communication of the treatment plan to other relevant professionals. However, the assessment of capacity issues and acquizition of consent or assent were rarely documented. The results highlighted certain areas of clinical practice that may need to be formally documented in patient case notes in order to provide evidence of the quality of healthcare an individual has received.

Diagnostic laparoscopy: indications and benefits.

The increased availability of treatment options for gastrointestinal cancer, necessitates precise preoperative staging. Laparoscopy can be useful for establishing the diagnosis and staging of cancer. However, there is an ongoing discussion as to whether staging laparoscopy provides additional results despite newly developed imaging tools. A systematic review of relevant literature was undertaken. The strength of evidence was classified according to the North of England Evidence Based Guidelines Development Project. Medline and manual searches were carried out to identify all published manuscripts of clinical trials that dealt with staging laparoscopy. Systematic quality review of those publications was used to verify staging accuracy, complications and trocar metastases. Only one randomized trial was performed in gynaecological cancer. In cervical cancer, as a result of this study, staging laparoscopy remains unproven. In gastrointestinal cancer (oesophageal, gastric, pancreatic, liver and colorectal cancers) only prospective and retrospective observational studies are available with an evidence-based level of grade B. As a result of these trials, staging laparoscopy, in a well-defined group of patients with locally advanced cancer, is recommended. The effects of surgical staging in gynaecological cancer must be kept in mind but cannot be transferred to gastrointestinal cancer in general. Further studies are required to answer those questions.

Guidelines on the use of liver biopsy in clinical practice

Erlich is credited with the first liver aspiration in 1883 and subsequently the first percutaneous liver biopsy for diagnostic purposes was reported in 1923.1 The technique has been modified since...

DERIVING TREATMENT RECOMMENDATIONS FROM EVIDENCE WITHIN RANDOMIZED TRIALS The Role and Limitation of Meta-Analysis

Meta-analysis is commonly used in reviews of the effectiveness of medical technologies, but this approach has not been used in direct support of guidelines development groups. This paper describes the approach of the North of England Guidelines Development Project in describing the evidence using meta-analyses that were conducted explicitly to address questions on the choice of therapy raised by the guidelines development groups. Particular emphasis is placed on the context within which the contributing trials were conducted and the extent to which systematic differences between trials (heterogeneity) was observed, described, and explained. There is a trade-off between internal and external validity for different metrics when presenting the results of trials. More interpretable metrics, such as risk differences or weighted mean differences, are confounded by study design issues and strong assumptions. More robust measures such as odds ratios or standardized weighted mean differences are difficult to interpret physically. Individual patient data may prove particularly helpful in addressing pivotal questions on the magnitude of effects of interventions, though accessing and reanalyzing these data requires a substantial investment in time and other resources.

North of England evidence based guidelines development project: summary version of evidence based guideline for the primary care management of stable angina

The aim of this guideline is to provide recommendations to aid primary health care professionals in their management of patients with chronic stable angina due to coronary artery disease (not aortic stenosis or hypertrophic obstructive cardiomyopathy). It does not deal with unstable angina or myocardial infarction. It is a summary version of the full guideline,1 to which reference should be made for clarification or further information. The development group assumes that health care professionals will use general medical knowledge and clinical judgment in applying the general principles and specific recommendations in this document to the management of individual patients. Recommendations may not be appropriate for use in all circumstances. Decisions to adopt any particular recommendation must be made by the practitioner in the light of available resources and circumstances presented by individual patients. Throughout this guideline categories of evidence (cited as I, II, and III) and the strength of recommendations (A, B, or C) are as described in the paper in the previous issue (23 March, p 760). Aspects covered by this guideline are investigation, risk factor identification and management, drug treatment, and referral. All recommendations are for primary health care professionals and apply to adult patients attending general practice with angina. Comment—Assessment will be based on a clinical history and relevant examination. This guideline requires that the following should be known: precipitants of anginal attacks; smoking history; occupation; amount of exercise taken; drug history; weight; blood pressure. Comment—The group thought that a chronological age limit for investigation or referral was not appropriate. Functional status was thought to be more appropriate. ### Precipitating factors RECOMMENDATION ### Investigation of angina RECOMMENDATION Patients being investigated for angina should have the following investigations:

North of England evidence based guidelines development project: methods of guideline development

There is increasing interest in clinical guidelines in Britain. With this interest has come increasing awareness of the methodological issues in the development of valid guidelines.1 2 3 Practice guidelines are considered valid if “when followed, they lead to the health gains and costs predicted for them.”1 When appropriately disseminated and implemented, valid guidelines can lead to changes in clinical practice and improvements in patient outcome.4 5 6 7 Conversely, the dissemination and implementation of invalid guidelines may lead to wasteful use of resources on ineffective interventions or, worse, deterioration in patients' health. Validity has been related to three principal factors in guideline development—namely, the composition of the guideline development panel and its processes; the identification and synthesis of evidence; and the method of guideline construction.5 Though these factors have been discussed at theoretical5 and more practical levels,8 there have been few attempts to put them into practice in Britain. In this series of three papers we describe the methods used to develop evidence based guidelines for the primary care management of two common chronic conditions—namely, asthma in adults and stable angina—and summary versions of the two guidelines that resulted.9 10 The guideline development groups were composed of relevant health care professionals and patients; a specialist resource (a consultant chest physician for asthma and a consultant cardiologist for stable angina) and an experienced small group leader; and members of the research team. All group members …

North of England evidence based guidelines development project: summary version of evidence based guideline for the primary care management of asthma in adults

North of England evidence based guidelines development project: summary version of evidence based guideline for the primary care management of asthma in adults

Developing valid guidelines: methodological and procedural issues from the North of England Evidence Based Guideline Development Project.

Thereisincreasing interest inclinical guidelines within theUnitedKingdom. Withthis interest hascomeanincreasing awareness of themethodological issues involved inguideline development, although reports arelimited.' Woolfdescribed threemainmethodsof guideline development: informal consensus, formal consensus, andevidence linked.2 In guidelines developed through informal consensus, themethodusedmostofteninthe UnitedKingdom,theguideline panelhas poorly defined, oftenimplicit, criteria for decision making. Development by formal consensus, usedby many consensusdevelopment conferences andDelphi groups, provides greater structure totheanalytical process butstill fails toprovide anexplicit