Traditional Clinical Practice Guidelines Lifecycle

Figure 1 - Traditional Clinical Practice Guidelines Lifecycle

It is now clear that CPGs must be evidence-based. Normally they are the result of a well defined methodology, usually adopted at organization level in order to guide the development of all the CPGs within that organization. The accepted criteria for validity of guidelines have evolved from the 'essential elements of good guidelines' identified by the US Institute of Medicine in 1990 [1]. These recommended 'attributes of good guidelines' included validity, reliability, clinical applicability, clinical flexibility, clarity, multidisciplinary process, scheduled review, and documentation. The recommendations were underpinned by the twin themes of credibility and accountability:

"The link between a set of guidelines and the scientific evidence must be explicit, and scientific and clinical evidence should take precedence over expert judgment".

Most of the methods for CPG development, such as the already mentioned SIGN's original Criteria for Appraisal of Clinical Guidelines for National Use [2], and the more recent AGREE (Appraisal of Guidelines, Research and Evaluation for Europe) guideline appraisal instrument are based on these founding principles of guideline development [3].

Without going into the deepest details, the CPG development process or life cycle can be summarized as in figure 2.6 in which it is quite clear that the dissemination of CPGs is under textual form (books or nowadays hypertext documents). An example of a detailed CPG development process consists in the overview of the SIGN guideline development process in figure 2.7.

Figure 2 - Overview of the SIGN guideline development process
(from SIGN 50:A guideline developers' handbook)

A common scenario

Thus, a common scenario is represented by a clinician with several books on the desk or in the some cases with hypertext documents on a computer for a faster retrieval of the needed information and possibly a faster and cheaper dissemination. Unfortunately, traditional textual CPGs may lead to different class of problems in clinical practice:

The interpretation may be not unique. CPGs can be semantically very complex and to have a clear understanding of health care tasks sequence is not always easy, as paths are distributed in the whole text. The interpretation of CPGs involves the generation of inferences that are needed for correctly implementing the procedure prescribed by the guideline. The fact that interpretation requires making inferences may discover ambiguities of textual CPGs, in other words it often happens that they are prone to different interpretations by different physicians;
Organisational constraints limit the implementation of the official CPGs. CPGs are distributed as medical models and they don't usually take care about organization characteristics. In order to be effective it is often needed to adapt the generic model to a specific reality. This adaptation process is hardly performed on textual CPGs, than most of the times the adaptation will be performed, implicitly, by the physician himself, during the CPGs usage. Such changes often are not documented explicitly;
Health care operators often do not fully comply with CPGs for several reasons and it is really important to keep track of the motivations behind non compliances. Performing this process on the paper is quite ineffective over a long time period;
The health care process must be contextualized on a specific patient. Certainly textual formats cannot change their shape in front of the patient problems and needs.

For these reasons and for producing alerts and remainders or in general patient-tailored suggestions, it is necessary to computerize CPGs.

Computerized Clinical Practice Guidelines Lifecycle »

References

[1] Field MJ, Lohr KN (Editors)
Clinical practice guidelines: directions for a new program.
Committee to Advise the Public Health Service on Clinical Practice Guidelines

[2] Scottish Intercollegiate Guidelines Network (SIGN).
Clinical guidelines: criteria for appraisal for national use.
Edinburgh; SIGN: 1995

[3] Appraisal of Guidelines, Research and Evaluation for Europe website
http://www.agreecollaboration.org/

[4] SIGN 50:A guideline developers' handbook website
http://www.sign.ac.uk/guidelines/fulltext/50/index.html

Hck Laboratory

MEDICAL KNOWLEDGE MANAGEMENT CONTENT

SOME BOOKS

Traditional Clinical Practice Guidelines Lifecycle

A common scenario

References