evidence outcome summery

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Advancing Optimal Care with Robust Clinical Practice Guidelines

A review of terms noted for this chapter

Integrative reviews: Systematic summaries of the accumulated state of knowledge about a concept, including highlights of important issues left unresolved.

Systematic review:A summary of evidence, typically conducted by an expert or expert panel on a particular topic, that uses a rigorous process (to minimize bias) for identifying, appraising, and synthesizing studies to answer a specific clinical question and draw conclusions about the data gathered.

Internal evidence: Evidence generated within a clinical practice setting from initiatives such as quality improvement, outcomes management, or EBP implementation projects

Level of evidence: A ranking of evidence by the type of design or research methodology that would answer the question with the least number of error and provide the most reliable findings. Leveling of evidence, also called hierarchies, vary by type of question asked. An example is provided for intervention questions.

For this course we reference JH levels- you should JH for the quiz and final

Cont’d terms to know

Meta-analysis-A process of using quantitative methods to summarize the results from the multiple studies, obtained and critically reviewed using a rigorous process (to minimize bias) for identifying, appraising, and synthesizing studies to answer a specific question and draw conclusions about the data gathered. The purpose of this process is to gain a summary statistic (i.e., a measure of a single effect) that represents the effect of the intervention across multiple studies.

Randomized controlled trials- A true experiment (i.e., one that delivers an intervention or treatment in which participants are randomly assigned to control and experimental groups); the -strongest design to support cause-and-effect relationships.

Rapid Critical Appraisal- The process of evaluating a study for its worth (i.e., validity, reliability, and applicability to clinical practice).

CPGs and EBPGs

Clinical Practice Guidelines (or CPGs) are systematically developed statements to assist clinicians and patients in making decisions about care.

VS.

Evidence-Based Practice Guidelines (EBPGs) are systematically developed statements based on the best available evidence, including synthesis, make recommendations in order to assist practitioners with decisions regarding the most effective interventions for specific clinical conditions across a broad array of clinical diagnoses and situations.

The focus of CPG’s & EBPG’S

CPGs & EBPG’S should focus on outcomes that are meaningful to patients, not providers.

Other qualities of a well-done EBPG or CPG include addressing how often interventions or screenings should occur to achieve optimal outcomes, addressing clinically relevant actions, and identifying a rating scheme or similar method used to determine the quality and strength of the studies included.

Clinical Practice Guidelines (CPGs)

Clinical Practice Guidelines (or CPGs) Consist of a systematic review of the literature

Consensus of a group of expert decision makers

Administrators

Policy makers

Clinicians

Consumers

Group of experts considers the evidence and makes recommendations.

: CPGs are based on the best available evidence, but it is the responsibility of the clinician to integrate patient preferences and clinical expertise into consideration when planning care.

10 Key Visions for Clinical Practice Guideline ( CPG) Development

1. Make evidence available on a worldwide basis

2. Focus on questions important to patients and clinicians and include relevant stakeholders

3. Undertake collaborative evidence reviews relevant to health care questions and recommendations

4. Use a common metric to assess the quality of evidence and strength of recommendations

5. Consider comorbidities in guideline development

10 Key Visions for Clinical Practice Guideline ( CPG) Development

6. Identify ways that help guideline consumers understand and implement guidelines using the best available tools.

7. Deal with conflicts of interest and guideline sponsoring transparently

8. Support development of decision aids to assist implementation of value-and preference-sensitive guideline recommendations

9. Maintain a collaboration of international organizations

10. Examine collaborative models for funding guideline development and implementation

Accessing Evidenced -Based Practice Guidelines ( EBPG)

Organizations that house collections of practice guidelines have grown.

General guideline databases created and housed by organizations such as:

U.S. Preventive Task Force

The Community Guide

Registered Nurses’ Association of Ontario

National Institute for Health and Clinical Excellence (NICE)

Cont’d : Accessing Evidenced -Based Practice ( EBPG) Guidelines

Specific guidelines are being produced and housed by such organizations as:

American College of Physicians (ACP)

National Kidney Foundation

National Association of Neonatal Nurses (NANN)

Oncology Nursing Society (ONS)

Practice guidelines are also housed in some of the electronic databases such as PubMed.

What Makes a Sound Guideline?

Consider the following when reading guidelines:

Are the recommendations unambiguous as possible?

Do the developers address how often interventions or screenings should occur to achieve optimal outcomes?

Are the developers explicit about where informing the patient of choices could lead to varying decisions?

Do the recommendations address clinically relevant actions?

Do the developers include an assessment of the benefits vs. the harms of implementing (supported by documentation)?

Cont’d :What Makes a Sound Guideline?

Do the developers focus on outcomes that are meaningful to patients?

Do the developers include all reasonable treatment options for a given condition or disease?

Did the developers fully describe the process used to systematically search and review the evidence on which the guideline recommendations are based?

Did the developers identify a rating scheme or similar method used to determine the quality and strength of the studies included?

NOTE: BECAUSE CPGs reflect evidence at a point in time, they require consistent updating.

Grading Recommendations of EBPGs

Recommendations within an EBPG or CPG are each based on a unique body of evidence specific to that recommendation.

Some evidence is stronger than other evidence.

Recommendations are often graded to reflect the strength of the evidence supporting that particular recommendation within the EBPG or CPG.

Although well-done EBPGs or CPGs are based on the best available evidence, sometimes there isn’t sufficient evidence available to support making a recommendation.

The strength of the body of evidence is not consistent across all recommendations within an EBPG or CPG. Therefore, all recommendations are not created equal. Grading recommendations within an EBPG or CPG provides guidance to providers as they work to provide optimal care.

Examples of Grading Recommendations of EBPGs

The AGREE instrument: Six areas of appraisal

Scope and purpose

Stakeholder involvement

Rigor of development

Clarity and presentation

Application

Editorial independence

Rapid Critical Appraisal of EBPGs

Is the guideline valid and reliable?

Who were the guideline developers and were they representative of key stakeholders?

Who funded the guideline development and were any of the guideline developers funded researchers of the reviewed studies?

Was an explicit, sensible, and impartial process used to identify, select, and combine evidence?

Did its developers carry out a comprehensive, reproducible literature review within the past 12 months of guideline publication/revision? Were all important options and outcomes considered?

Rapid Critical Appraisal (RCA) of EBPGs

Institute of Medicine’s ( IOM) eight attributes of good guideline development:

1. Validity

2. Reliability and reproducibility

3. Clinical applicability

4. Clinical flexibility

5. Clarity

6. Documentation

7. Development by a multidisciplinary process

8. Plans for review

Tools to do Rapid Critical Appraisal of EBPGs

Rapid Critical Appraisal Checklist

Appraisal of Guidelines for Research and Evaluation Instrument for Assessing Guidelines (AGREE II)

Conference on Guideline Standardization (COGS) recommendations

EBP FAST FACTS

Clinical practice guidelines are statements that include recommendations for practice based on a systematic review of evidence along with the benefits and harm of interventions intended to optimize patient care and outcomes.

Clinical practice guidelines that are rigorously developed reduce variations in care and enhance healthcare quality and patient outcomes.

Not all clinical practice guidelines that are published follow rigorous methods in their development, which is why critical appraisal of guidelines before adopting them for implementation in clinical practice settings is necessary.

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EBP FAST FACTS cont’d

An excellent exemplar of the process used to develop rigorous evidence-based clinical recommendations can be found in the procedure manual used by the U.S. Preventive Services Task Force (see https://www.uspreventiveservicestaskforce.org/Page/Name/procedure-manual).

Implementing evidence-based guidelines in daily clinical practice requires a multifaceted and sustained approach with individual and systemic interventions, including individual skills building, along with factors such as developing a culture and context that support EBP, providing EBP champions and mentors, and administrative support that includes the provision of tools that support implementation of evidence-based guidelines and recommendations.

evidence outcome summery

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