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BMC Health Services Research
Published in: BMC Health Services Research 1/2017

Open Access 01-12-2017 | Research article

Reaching beyond the review of research evidence: a qualitative study of decision making during the development of clinical practice guidelines for disease prevention in healthcare

Authors: Linda Richter Sundberg, Rickard Garvare, Monica Elisabeth Nyström

Published in: BMC Health Services Research | Issue 1/2017

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Abstract

Background

The judgment and decision making process during guideline development is central for producing high-quality clinical practice guidelines, but the topic is relatively underexplored in the guideline research literature. We have studied the development process of national guidelines with a disease-prevention scope produced by the National board of Health and Welfare (NBHW) in Sweden. The NBHW formal guideline development model states that guideline recommendations should be based on five decision-criteria: research evidence; curative/preventive effect size, severity of the condition; cost-effectiveness; and ethical considerations. A group of health profession representatives (i.e. a prioritization group) was assigned the task of ranking condition-intervention pairs for guideline recommendations, taking into consideration the multiple decision criteria. The aim of this study was to investigate the decision making process during the two-year development of national guidelines for methods of preventing disease.

Methods

A qualitative inductive longitudinal case study approach was used to investigate the decision making process. Questionnaires, non-participant observations of nine two-day group meetings, and documents provided data for the analysis. Conventional and summative qualitative content analysis was used to analyse data.

Results

The guideline development model was modified ad-hoc as the group encountered three main types of dilemmas: high quality evidence vs. low adoptability of recommendation; insufficient evidence vs. high urgency to act; and incoherence in assessment and prioritization within and between four different lifestyle areas. The formal guideline development model guided the decision-criteria used, but three new or revised criteria were added by the group: ‘clinical knowledge and experience’, ‘potential guideline consequences’ and ‘needs of vulnerable groups’. The frequency of the use of various criteria in discussions varied over time. Gender, professional status, and interpersonal skills were perceived to affect individuals’ relative influence on group discussions.

Conclusions

The study shows that guideline development groups make compromises between rigour and pragmatism. The formal guideline development model incorporated multiple aspects, but offered few details on how the different criteria should be handled. The guideline development model devoted little attention to the role of the decision-model and group-related factors. Guideline development models could benefit from clarifying the role of the group-related factors and non-research evidence, such as clinical experience and ethical considerations, in decision-processes during guideline development.
Literature
1.
Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet. 2003;362(9391):1225–30.CrossRefPubMed
2.
Brown LC, Johnson JA, Majumdar SR, Tsuyuki RT, McAlister FA. Evidence of suboptimal management of cardiovascular risk in patients with type 2 diabetes mellitus and symptomatic atherosclerosis. CMAJ. 2004;171(10):1189–92.CrossRefPubMedPubMedCentral
3.
4.
McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(26):2635–45.CrossRefPubMed
5.
Glasgow RE, Lichtenstein E, Marcus AC. Why don’t we see more translation of health promotion research to practice? Rethinking the efficacy-to-effectiveness transition. Am J Public Health. 2003;93(8):1261–7.CrossRefPubMedPubMedCentral
6.
Delgado-Noguera M, Tort S, Bonfill X, Gich I, Alonso-Coello P. Quality assessment of clinical practice guidelines for the prevention and treatment of childhood overweight and obesity. Eur J Pediatr. 2009;168(7):789–99.CrossRefPubMed
7.
8.
Turner T, Misso M, Harris C, Green S. Development of evidence-based clinical practice guidelines (CPGs): comparing approaches. Implementation science. 2008;3:45.CrossRefPubMedPubMedCentral
9.
Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ. 2010;182(18):E839–42.CrossRefPubMedPubMedCentral
10.
Gagliardi AR, Brouwers MC, Palda VA, Lemieux-Charles L, Grimshaw JM. How can we improve guideline use? A conceptual framework of implementability Implementation science. 2011;6:26.CrossRefPubMed
11.
Grol R, Wensing M. What drives change? Barriers to and incentives for achieving evidence-based practice. Med J Aust. 2004;180(6 Suppl):57–60.
12.
Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. Jama. 1999;282(15):1458–65.CrossRefPubMed
13.
Francke AL, Smit MC, Veer de AJ, Mistiaen P. Factors influencing the implementation of clinical guidelines for health care professionals: a systematic meta-review. BMC Med Inform Decis Mak. 2008;8:38.CrossRefPubMedPubMedCentral
14.
Shiffman RN, Dixon J, Brandt C, Essaihi A, Hsiao A, Michel G, et al. The GuideLine Implementability appraisal (GLIA): development of an instrument to identify obstacles to guideline implementation. BMC Med Inform Decis Mak. 2005;5:23.CrossRefPubMedPubMedCentral
15.
Richter-Sundberg L, Kardakis T, Weinehall L, Garvare R, Nystrom ME. Addressing implementation challenges during guideline development - a case study of Swedish national guidelines for methods of preventing disease. BMC Health Serv Res. 2015;15:19.CrossRefPubMedPubMedCentral
16.
Qaseem A, Forland F, Macbeth F, Ollenschlager G, Phillips S, Wees van der P. Guidelines International Network: toward international standards for clinical practice guidelines. Ann Intern Med. 2012;156(7):525–31.CrossRefPubMed
17.
Eccles MP, Grimshaw JM, Shekelle P, Schunemann HJ, Woolf S. Developing clinical practice guidelines: target audiences, identifying topics for guidelines, guideline group composition and functioning and conflicts of interest. Implementation science. 2012;7:60.CrossRefPubMedPubMedCentral
18.
Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336(7650):924–6.CrossRefPubMedPubMedCentral
19.
Grol R, Cluzeau FA, Burgers JS. Clinical practice guidelines: towards better quality guidelines and increased international collaboration. Br J Cancer. 2003;89 Suppl 1:4–8.CrossRef
20.
Oxman AD, Fretheim A, Schunemann HJ. Improving the use of research evidence in guideline development: introduction. Health research policy and systems. 2006;4:12.CrossRefPubMedPubMedCentral
21.
Gopalakrishna G, Langendam MW, Scholten RJ, Bossuyt PM, Leeflang MM. Guidelines for guideline developers: a systematic review of grading systems for medical tests. Implementation science. 2013;8:78.CrossRefPubMedPubMedCentral
22.
Hemingway H, Chen R, Junghans C, Timmis A, Eldridge S, Black N, et al. Appropriateness criteria for coronary angiography in angina: reliability and validity. Ann Intern Med. 2008;149(4):221–31.CrossRefPubMed
23.
Atkins L, Smith JA, Kelly MP, Michie S. The process of developing evidence-based guidance in medicine and public health: a qualitative study of views from the inside. Implementation science. 2013;8:101.CrossRefPubMedPubMedCentral
24.
25.
Black N, Murphy M, Lamping D, McKee M, Sanderson C, Askham J, et al. Consensus development methods: a review of best practice in creating clinical guidelines. J Health Serv Res Policy. 1999;4(4):236–48.CrossRefPubMed
26.
National Institute for Health and Care Excellence (NICE). Process and Methods guides. Developing NICE guidelines: the manual. [Internet] 2014 [cited 12 may 2015] Available from: https://​www.​nice.​org.​uk/​media/​default/​about/​what-we-do/​our-programmes/​developing-nice-guidelines-the-manual.​pdf
27.
Aldrich R, Kemp L, Williams JS, Harris E, Simpson S, Wilson A, et al. Using socioeconomic evidence in clinical practice guidelines. BMJ (Clinical research ed). 2003;327(7426):1283–5.CrossRef
28.
Oxman AD, Schunemann HJ, Fretheim A. Improving the use of research evidence in guideline development: 12. Incorporating considerations of equity Health research policy and systems. 2006;4:24.PubMed
29.
Fredriksson M, Blomqvist P, Winblad U. Recentralizing healthcare through evidence-based guidelines - striving for national equity in Sweden. BMC Health Serv Res. 2014;14:509.CrossRefPubMedPubMedCentral
30.
Eccles M, Mason J. How to develop cost-conscious guidelines. Health Technol Assess. 2001;5(16):1–69.CrossRefPubMed
31.
Petrie JC, Grimshaw JM, Bryson A. The Scottish Intercollegiate Guidelines Network Initiative: getting validated guidelines into local practice. Health Bull. 1995;53(6):345–8.
32.
Fretheim A, Schunemann HJ, Oxman AD. Improving the use of research evidence in guideline development: 3. Group composition and consultation process Health research policy and systems. 2006;4:15.CrossRefPubMed
33.
Grilli R, Magrini N, Penna A, Mura G, Liberati A. Practice guidelines developed by specialty societies: the need for a critical appraisal. Lancet. 2000;355(9198):103–6.CrossRefPubMed
34.
Boluyt N, Lincke CR, Offringa M. Quality of evidence-based pediatric guidelines. Pediatrics. 2005;115(5):1378–91.CrossRefPubMed
35.
de Haas ER, de Vijlder HC, van Reesema WS, van Everdingen JJ, Neumann HA. Quality of clinical practice guidelines in dermatological oncology. J Eur Acad Dermatol Venereol. 2007;21(9):1193–8.PubMed
36.
Gagliardi AR, Brouwers MC. Integrating guideline development and implementation: analysis of guideline development manual instructions for generating implementation advice. Implementation science. 2012;7:67.CrossRefPubMedPubMedCentral
37.
Hopthrow T, Feder G, Michie S. The role of group decision making processes in the creation of clinical guidelines. Int Rev Psychiatry. 2011;23(4):358–64.CrossRefPubMed
38.
Grimshaw J, Eccles M, Russell I. Developing clinically valid practice guidelines. J Eval Clin Pract. 1995;1(1):37–48.CrossRefPubMed
39.
Burgers JS, Bailey JV, Klazinga NS, Van Der Bij AK, Grol R, Feder G. Inside guidelines: comparative analysis of recommendations and evidence in diabetes guidelines from 13 countries. Diabetes Care. 2002;25(11):1933–9.CrossRefPubMed
40.
Gill PJ, Wang KY, Mant D, Hartling L, Heneghan C, Perera R, et al. The evidence base for interventions delivered to children in primary care: an overview of cochrane systematic reviews. Plos one. 2011;6(8):23051.CrossRef
41.
42.
Hasson F, Keeney S, McKenna H. Research guidelines for the Delphi survey technique. J Adv Nurs. 2000;32(4):1008–15.PubMed
43.
44.
Cantrill JA, Sibbald B, Buetow S. The Delphi and nominal group techniques in health services research. International Journal of Pharmacy Practice. 1996;4(2):67–74.CrossRef
45.
Hutchings A, Raine R. A systematic review of factors affecting the judgments produced by formal consensus development methods in health care. J Health Serv Res Policy. 2006;11(3):172–9.CrossRefPubMed
46.
Glasier A, Brechin S, Raine R, Penney G. A consensus process to adapt the World Health Organization selected practice recommendations for UK use. Contraception. 2003;68(5):327–33.CrossRefPubMed
47.
Kahan JP, Park RE, Leape LL, Bernstein SJ, Hilborne LH, Parker L, et al. Variations by specialty in physician ratings of the appropriateness and necessity of indications for procedures. Med Care. 1996;34(6):512–23.CrossRefPubMed
48.
Murphy MK, Black NA, Lamping DL, McKee CM, Sanderson CF, Askham J, et al. Consensus development methods, and their use in clinical guideline development. Health Technol Assess. 1998;2(3):1–88.
49.
Raine R, Sanderson C, Hutchings A, Carter S, Larkin K, Black N. An experimental study of determinants of group judgments in clinical guideline development. Lancet. 2004;364(9432):429–37.CrossRefPubMed
50.
Pagliari C, Grimshaw J, Eccles M. The potential influence of small group processes on guideline development. J Eval Clin Pract. 2001;7(2):165–73.CrossRefPubMed
51.
Shekelle PG, Schriger DL. Evaluating the use of the appropriateness method in the agency for health care policy and research clinical practice guideline development process. Health Serv Res. 1996;31(4):453–68.PubMedPubMedCentral
52.
Pagliari C, Grimshaw J. Impact of group structure and process on multidisciplinary evidence-based guideline development: an observational study. J Eval Clin Pract. 2002;8(2):145–53.CrossRefPubMed
53.
54.
Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277–88.CrossRefPubMed
55.
Gustafson DH, Shukla RK, Delbecq A, Walster GW. A comparative study of differences in subjective likelihood estimates made by individuals, interacting groups, delphi groups, and nominal groups. Organ Behav Hum Perf. 1973;9:280–91. doi:10.​1016/​0030-5073(73)90052-4.
56.
Eubank BH, Mohtadi MR, Lafave MR, Preston JW, Bois AJ, Boorman RS, et al. Using the modified Delphi method to establish clinical consensus for the diagnosis and treatment of patients with rotator cuff pathology. BMC Med Res Methodol. 2016;16:56. doi:10.​1186/​s12874-016-0165-8.
57.
Browman GP, Somerfield MR, Lyman GH, Brouwers MC. When is good, good enough? Methodologicalpragmatism for sustainable guideline development. Implement Sci. 2015;10:28.
58.
59.
Rycroft-Malone J, Seers K, Titchen A, Harvey G, Kitson A, McCormack B. What counts as evidence in evidence-based practice? J Adv Nurs. 2004;47(1):81–90.CrossRefPubMed
60.
Cluzeau F, Wedzicha JA, Kelson M, Corn J, Kunz R, Walsh J, Schunemann HJ. Stakeholder Involvement: How to Do It right article 9 in integrating and coordinating efforts in COPD guideline development. An official ATS/ERS workshop report. Proc Am Thorac Soc. 2012;9(5):269–73.CrossRefPubMed
61.
Moynihan R, Oxman AD, Lavis J, Paulsen E. A review of organizations that support the use of research evidence in developing guidelines, technology assessments, and health policy, for the WHO advisory committee on health research. Oslo: Norwegian Knowledge Centre for the Health Services; 2006.
62.
National Institute for Health and Clinical Excellence: Developing NICE guidelines: the manual. Process and methods guides. London: National Institute for Health and Clinical Excellence; 2014. p. 240.
63.
Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4:50. doi:10.​1186/​1748-5908-4-50.
Metadata
Title
Reaching beyond the review of research evidence: a qualitative study of decision making during the development of clinical practice guidelines for disease prevention in healthcare
Authors
Linda Richter Sundberg
Rickard Garvare
Monica Elisabeth Nyström
Publication date
01-12-2017
Publisher
BioMed Central
Published in
BMC Health Services Research / Issue 1/2017
Electronic ISSN: 1472-6963
DOI
https://doi.org/10.1186/s12913-017-2277-1

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