Canadian Medical Association Journal 1995; 153: 1715-1719
Paper reprints of the full text may be obtained from: Dr. Anne O. Carter, Department of Health Care and Promotion, Canadian Medical Association, PO Box 8650, Ottawa ON K1G 0G8
Contents
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Introduction
In line with the recommendations of a workshop on clinical practice guidelines (CPGs) held in Ottawa on Nov. 15 to 17, 1992,(1-7) an advisory committee representing the main stakeholder and funding groups was formed to plan a second workshop with the primary goal of identifying the key CPG issues and making recommendations in the following areas: the roles of organizations, priority setting, dissemination and implementation of guidelines, and evaluation. The second goal was to agree on the definition, structure and functions of a network of active CPG participants. The last goal was to improve participants' skills in the areas of electronic access to CPGs and the use of CPGs as a tool for continuing medical education.
The second workshop, held in Ottawa on Oct. 31 and Nov. 1, 1994, comprised five main sessions on the key issues arising from the first two goals. Two concurrent educational sessions focused on the third goal. Participants represented national, provincial and territorial organizations currently involved or interested in becoming involved in the guidelines field. Before the workshop they were sent a background paper on each of the five key issues along with a questionnaire on their activities and attitudes with regard to these issues, as described in the first five articles of this workshop series.(8-12) Each of the five main sessions included a plenary presentation, small group discussions and a period of feedback. This report summarizes the proceedings of the sessions.
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Organizational roles
The session led to discussions and conclusions that moved beyond the positions revealed in the preworkshop survey.(8) The realities and implications of health care reform required a reconsideration of involvement in CPG processes. Although the participants continued to strongly support guidelines grounded in science and carefully accumulated evidence, they also recognized that these technical aspects cannot be isolated from the more general forces affecting health and health care.
The participants agreed on a broad, inclusive set of processes for CPG development, validation, dissemination and evaluation. It was felt that partnerships between physicians, managers and governing boards will be necessary for optimal CPG development and implementation.
The important role of consumers was a powerful theme that extended throughout the workshop. Although the survey responses relegated consumers to minor roles at best, the workshop participants assigned them a prominent position in priority setting and even CPG development. If we are serious about health care being a partnership between providers and consumers, the latter must be informed about and involved in the discussions of evidence and best practice and in the assignment of values.
Although the participants generally supported eliminating needless and inefficient duplication of effort, they also noted the importance of local and provincial validation of and comfort with proposed CPGs. On these grounds they agreed that national coordinating bodies might best assist by gathering evidence in a systematic and comprehensive fashion. Local bodies may need to produce their own guidelines, even if they are virtually identical, to increase the likelihood of dissemination and implementation. As the CPG "industry" matures, physicians may become more comfortable with national guidelines; but in reality all health care decisions and processes are local and take place within different contexts and cultures.
The main conclusion was that participants in the overall development of the health care system deserve to be involved in CPG development as well. CPGs, health policy and resource allocation all influence each other; the objective should be to ensure that they are based on a shared understanding of issues and priorities. Technical and scientific information must be made accessible to consumers and managers, and the proponents of and experts in evidence-based medicine must be familiar with issues of governance and resource allocation.
Finally, points of view on the role of organized medicine in CPG processes were mixed. The perspectives were practical: if the participation of organized medicine would increase the quality and uptake of CPGs it should be pursued. Medical experts (e.g., those from specialty societies) should be part of the evidence-gathering and deliberative processes. Whether they should be expected to represent official positions was not ultimately resolved.
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Priority setting
Setting priorities for guidelines efforts requires consideration of a range of issues. After a review of the literature the workshop participants ranked six criteria for priority setting. They clearly ranked burden of disease and the likelihood of CPGs to reduce this burden over economic issues.(10)
The participants considered several questions that addressed the appropriate role of cost motives in selecting guidelines topics, the scope and form of stakeholders' involvement in guidelines activities and the selection of a process appropriate to a given guidelines effort. The participants expressed widely diverse views on cost motives in guidelines development; in terms of process, they were unlikely to favour a purely analytic or purely implicit approach to priority setting.
The participants identified 16 high-priority topics for guidelines development:
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Dissemination and implementation
Over 100 trials have tested methods of improving practice performance.(11) They have shown that practice can be improved and, to a lesser extent, patient outcomes enhanced through several procedures, alone and in combination: providing clinical preceptorships; auditing practices and giving feedback; channelling guidelines through the physicians in each community who are opinion leaders; using academic detailing and other outreach methods from universities and professional bodies; building care reminders into office information systems; sponsoring local consensus processes; marketing; and using patient-mediated interventions.
Canadian examples of guidelines implementation and continuing education using some of these effective methods include the programs of the Society of Obstetricians and Gynaecologists of Canada, the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada. However, most of the organization representatives at the session indicated that they allocated few resources specifically to the dissemination of guidelines, even those they had prepared themselves.(8)
Most practitioners indicate that they try to keep up to date, but the means they report using seldom match those tested and found to be effective.(14,15) Explanations for this gap include lack of testing of the popular methods for keeping up to date (e.g., journal reading), lack of availability or the high cost of effective forms of continuing education, and physicians' ignorance about the validated forms of continuing education.
The workshop participants recommended that organizations involved in guidelines dissemination and implementation could enhance their effectiveness by heeding the lessons from research; emulating groups that have been successful in implementing guidelines; allocating a larger share of the resources for guidelines programs to areas such as dissemination, implementation and evaluation; and working with patients, the media, special-interest groups and industry (pharmaceutical and nonpharmaceutical) to foster effective means of disseminating and implementing guidelines of mutual interest. The intended recipients of guidelines (including practitioners, patients and the public) should be involved in guidelines development and dissemination. Continuing education and guidelines adherence should be made mandatory when appropriate. Preemptive or administrative forms of guidelines implementation, such as the discontinuation of redundant laboratory tests, should be used when there is irrefutable evidence and broad consensus supporting the guidelines.
New funding is needed to implement effective forms of dissemination. This could come from the usual sponsors of continuing education and could in part be found through a shifting of funding from ineffective means of dissemination, such as publication alone, non-needs-based continuing education and unsolicited advertising. Existing structures and organizations should be used whenever possible.
Research needs related to the dissemination and implementation of guidelines include more sophisticated testing of seemingly ineffective strategies; exploration of the relation between implementation strategies and specific types of guidelines and the milieu in which they are used; assessment of the cost-effectiveness of current dissemination efforts; development and testing of innovative strategies (e.g., targeting of both practitioners and their patients, using information technology, providing incentives); and testing of ways to discourage the use of ineffective dissemination methods.
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Evaluation
The participants reiterated that the primary goal of guidelines programs (health service programs within which guidelines play a central role) should be to improve the quality of health care. Other identified goals were to reduce the health burden, to improve access to appropriate health care, to improve cost-effectiveness and cost-benefit ratios, to improve appropriate utilization of resources, to improve communication between providers and consumers and to contribute to the continuing medical education of both providers and consumers.
Process and outcome measures may be used to assess the value of CPGs. Traditional process measures include length of stay, admission rates, utilization measures, cost and adherence to guidelines. Outcome targets include functional health status, rates of morbidity and mortality, patient and provider satisfaction and quality-of-life measures.
The evaluation of CPGs is an integral component in the guidelines process but the least routinely undertaken aspect of guidelines programs. To ensure its validity and timeliness the evaluation should be planned at the outset of guidelines development, before implementation. This planning would entail an assessment of the data and resources required for the evaluation as well as anticipation of the responses to both positive and negative results.
As for any other medical technology, guidelines must be routinely evaluated not only to ascertain whether the guidelines program is having the desired effect but also to guard against untoward results. The evaluation of CPGs should depend on the stage of the guidelines program, the goals of the program and the goals of the evaluation. At the development stage, evaluation may lead to changes in implementation strategies, changes in the program coverage, reassessment of the target audience or reallocation of resources. Few evaluations will entail full formal randomized trials.
There are significant barriers to the widespread and routine evaluation of guidelines programs. Adequate financial and personnel resources must be available. This underlies the importance of channelling available resources to the highest priority areas. The methods and data used for evaluations are, to date, underdeveloped. As the culture of accountability in health care increases, so too will the pressures to enhance the routine gathering of data that measure quality rather than to rely on simple accounting measures.
Guidelines assessments should be a voluntary form of self-audit and as such would form a dynamic aspect of continuing medical education and quality assurance. There is concern that monitoring compliance with guidelines would be acceptable only if the guidelines themselves had been evaluated and shown to be valid. The distinction between guidelines and standards must be reiterated in allowing variations from recommended practice in the case of guidelines but not of standards. Finally, the focus in the monitoring of practices should be on outcomes when possible rather than on simple adherence to guidelines.
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Building the Canadian CPG Network
The objectives of the network session were to reach agreement on the definition, functions and structure of
a CPG network. Four aspects of the network were considered, and for each one the participants were asked whether they agreed (i.e., could respond positively to the question "Can you live with it?") with certain questions that had been developed from the results of the pre-workshop survey.(8)
The first aspect related to the functions of the network. Most of the participants agreed with the following three important functions: (a) facilitation, cooperation and communication; (b) development and maintenance of a central information centre on CPGs and individuals and organizations active in the CPG field; and (c) provision of expertise in CPG processes.
Those who disagreed suggested that a number of centres be maintained, with information made available on the Internet, and that the network disseminate information rather than act as an expert in the area. Other comments centred on ensuring the quality of the guidelines process rather than on the quality of the guidelines themselves; other roles such as research, education and funding; increasing the acceptance of guidelines; and ensuring that both specialty and other organizations are fairly represented in the network.
The second aspect involved the structure and communications mechanisms of the network. The participants agreed that a formal structure was unnecessary; instead, they felt that the network should be developed in response to changing needs and should support efforts in the CPG field. This could involve a loose, informal structure or an initial formal structure with a sunset date. Existing organizations such as the CMA or the National Partnership for Quality in Health (NAPAQH) could act as a secretariat for the network, with a voluntary informal membership. There was agreement that some national grouping was essential but not on how this could be obtained. Suggestions included the establishment of defined tasks at the provincial level with a national communications mechanism, and a decentralized structure with a small steering group such as NAPAQH. Interactive communication would best be achieved with the help of electronic media such as the Internet. Workshops were seen as a valuable tool, as were newsletters and existing journals.
The third aspect involved defining the membership of the network. Most agreed that all interested or involved parties should have the option of joining the network. However, the goals, rights and responsibilities of membership need to be defined.
The fourth and last aspect involved identifying the future steps to develop the CPG network. The participants agreed that the next phase would be to organize a small working group to develop a proposal for consideration by the workshop participants.