Developing and using

evidence-based guidelines
Overview
Clinical Practice Guidelines (CPGs)
What are evidence-based CPGs?
Why make CPGs?
How are evidence-based CPGs made?
When should CPGs be made?
Where do we go from here?
There is a gap between todays
scientific advances and their application:
between what we know and what is
actually being done. Health work
teaches us with great rigour that action
without knowledge is wasted effort, just
as knowledge without action is wasted
resource.

LEE Jong-wook, WHO Director General
Clinical Problem
Observations
associations, prognosis
Applied Research
Clinical trials, comparative
studies
Basic Research
Physiology, biochemistry
pharmacology
Clinical Care
Implementation of
research
Framework for the use of evidence
to solve clinical problems
Basic mechanisms
of disease
Potential
treatments
or diagnostic tests
Effective
treatments
or diagnostic
tests

Audit, quality
improvement
Clinical expertise
Guidelines
Systematic reviews
What are evidence-based CPGs?
Systematically developed documents
designed to support clinical decision-
making based on the best available
evidence
What does systematically mean?
Clear, well explained process for finding,
evaluating and summarising evidence

CPG or Protocol?
Definition is not always clear
CPG usually is a big document
explains the development process,
includes all the evidence, and
provides all the detail
Protocol usually is a summary (short)
document that is used in practice
Why make CPGs?
Evidence-based CPGs:
improve patient outcomes
reduce healthcare costs
help get research into practice
help junior staff learn best practice
help standardise care
are becoming a requirement of many hospitals
CPG development is one of the
SEA-ORCHID outcomes

CPG Articles Indexed in PubMed
0
1000
2000
3000
4000
5000
6000
1995 2000 2005
# of articles
How are evidence-based CPGs made?
Rigorous process based on many
systematic reviews
Thorough searches for evidence
Detailed appraisal of evidence
Discussion of evidence with clinical
experts
Development of recommendations
CPG development: The theory
1. Define topic
& scope
3. Search for
existing CPGs
4. Develop
questions
5. Systematically
search for research
6. Appraise &
synthesise research
7. Draft
recommendations
8. Get consensus
9. Finalise
CPG
10. Implement &
evaluate
11. Revise & update
2. Create multidisciplinary
group with consumers
Determine scope of CPG
Diseases or condition/s addressed
Patient group inclusions and exclusions
Clinicians to use guidelines
(nurses, doctors, health aids)
Setting for guideline use
(hospital, health centre)


Form multidisciplinary group
Representatives of all relevant
professional groups and clinical areas
Consumers
Technical team
Develop clinical questions
What are the issues or questions that need
to be addressed by the CPG?
Diagnosis, assessment of severity, treatment,
review, admission/discharge
PICO, patient, intervention, comparison,
outcome
Identify and appraise evidence
Search for evidence to answer clinical
questions
Appraise identified evidence for quality and
relevance and synthesise
Summarise existence and quality of
evidence
Develop recommendations
Based on clear evidence or,
Based on consensus, noting lack of
evidence or,
Non-consensus statement
acknowledging uncertainty
Write 3 (or maybe 4) versions
Full clinical practice guideline
Decision-making algorithm(s)
Version for use in practice
Patient information
Consult & pilot test
Guideline development group sign off
Executive sign off
Pilot
Revise
Disseminate and implement
This is the tricky and important bit
Dissemination through
Hard copies
Internet
Intranet
CDROMs
Flyers

Evaluate and revise
Evaluate use and impact of CPG
Routinely collected data (LOS, admits,
representation)
Medical record audit (survey, appropriate use)
Revise and implement
Review and update CPG after ? years
What resources are required?
Time
People
With evidence skills
With clinical skills
With protected time
Access to research evidence
CPG development: The reality?
1. Define topic
6. ?Refer to research
9. Finalise
CPG
10. Put in folder
Are there other options?
Do nothing?
CPGs that are not evidence-based?
Looking for evidence to put into existing
protocols
Adaptation of existing CPGs
Guideline adaptation
1. Define topic
& scope
3. Search for
existing CPGs
4. Develop
questions
5. Systematically
search for research
6. Appraise &
synthesise research
7. Draft
recommendations
8. Get consensus
9. Finalise
CPG
10. Implement &
evaluate
11. Revise & update
Adapt for local use
2. Create multidisciplinary
group with consumers
Where to find existing CPGs
www.sign.ac.uk Scottish guideline
development site
www.nzgg.org.nz New Zealand guideline
development site
www.nice.org.uk British guideline
development site
www.guidelines.gov American database of
guidelines (not all are evidence-based)
Evaluating existing CPGs
Relevance
Quality
Applicability
Relevance
Compare to Scope
Topic & Clinical questions covered
How recently was the CPG developed?
Clinicians to use CPG
(nurses, doctors, health aids)
Setting for CPG use
(hospital, health centre)
Resources available
(equipment, medications)
Quality
Use AGREE criteria as a guide
Were systematic searches done to find
evidence?
Was evidence appraised for quality?
Was a multidisciplinary group consulted?
Were the CPG writers independent from
pharmaceutical companies?
Are clear recommendations made?
Applicability
Is the CPG easy to read?
Is the language clear?
Does the CPG have a good structure
and layout?
Are good summaries included?
When are CPGs most useful?
When there is clear evidence about best
practice
When there is variation in practice
When a new practice is being introduced
When new staff are being trained

Questions?
Thank you!