Clinical practice guidelines. A tool to improve clinical practice and the efficiency of the health system
Researcher in public policy in health
Clinical Practice Guidelines (CPG) are recommendations or statements developed systematically based on the scientific evidence available, clinical experience and the perspective of patients, with the aim of guiding health professionals in decision-making in circumstances specific clinics.
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The Clinical Practice Guidelines (CPGs ) are defined as “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.” (Institute of Medicine, 1990). CPGs are designed to help health professionals make better decisions in their clinical practices regarding patient care.
The main objectives of the CPGs are to:
1) To produce recommendations to improve de quality of care patients through pertinent actions
2) To reduce the unjustified clinical variability
3) To serve as useful tools to politicians and administrators because they promote the efficiency and quality of care in health systems.
Significantly, CPGs synthesize a large amount of evidence in an easy-to-use format to help clinicians in their clinical practice, as well as a good CPGs are flexible, concise, and clear. It is important to keep in mind that CPGs are not rules or laws, but rather a tool to provide orientation regarding clinical decisions in a specific context since it is possible to modify the decision in special situations. There are numerous CPGs in use, but some of them are not adequately based in evidence and/or are not defined through a systematic process. Some CPGs are based on consensus and expert opinions, although these kinds of CPG are more prone to bias.
Regarding the process used to define CPGs, it is possible to categorize the methodology in two general ways, a formal methodology or informal methodology (1). The table below shows the different types of CPGs and their key characteristics:
Due to the variability in the methodology to develop the different types of CPGs, it is important to evaluate the quality of the CPGs themselves, since the methodology and the quality of the CDGs can result in good recommendations and improvement in clinical results in the patients.
To improve the quality and ensure the use of the appropriate methodology, several different organizations have created in the last few decades, for example, an International Network of Guidelines (GIN) and toolkits to guide the CPG development process. In this way, numerous CPG developer groups (DGs) from all over the world are currently utilizing the same methodology; for example, the GRADE methodology has been the most important framework/agreement to evaluate and qualify the evidence and recommendations arising from the CPGs. This kind of agreement allows significant comparability between different CPGs and ensures high level of quality.
The development of CPGs can be done through a “de novo” process, an “adaptation” process, or an “adoption” process.
- Adaptation: The DG that have used the “adaptation” option have done so because it can reduce the time to develop the CPGs, thereby reducing human and other resources. On the other hand, other DGs that have used the adaption methodology highlighting its robustness. Nonetheless the fact is that the process is very extensive and requires a lot of experience. Different experiences with the adaption process show that there can also be challenges in updating the CPGs.
- Adoption: According to the evidence, it not a widely-used methodology. This is due, in part, to the fact that DGs using it have encountered difficulties in adopting recommendations developed in other contexts.
- De novo process has several advantages over the adaption and adoption methodologies, which include its reliability and the standardization that it facilitates. Furthermore, the updating process is much clearer. Some disadvantages are that researchers have described is that the de novo process requires more time and resources compared to the other ones, but these problems were not always present.
The decision to undertake the CPG development process and the decision to use the de novo, adoption, or adaptation methodology must be made based on several factors, namely, those related to the availability of economic resources, experience, human resources, and time.
Due to the variety of methods to define CPGs, an important recommendation for CPG users is to evaluate quality before using a particular method. For that purpose, the AGREE II methodology is an option, given that it is widely known and used by the DGs, the scientific community, and the interested parties.
“Knowledge translation” (KT) is a concept that has been used since 2000. One of the first institutions to use this concept was the Canadian Institute of Health who try to understand the gap between the research and its application in clinical practice. KT has been understood as a process that begins with the creation and transformation of knowledge into applicable tools. These tools are useful to inform clinical practice and policymakers to improve health outcomes. KT incorporates several important elements: knowledge; activities; and an analysis of the context in which the process will be undertaken. (3)
CPGs are one of the many tools that can be used to ensure KT (4). It is important to keep in mind, however, that the mere definition of CPGs it is not enough in and of itself to change clinical practice, improve health outcomes, and increase the overall efficiency of the health system. The evidence shows that CPGs often do not apply to all situations. One reason for this is the sometimes limited capacity of practitioners to implement them. To achieve an effective CPG implementation process, it is therefore necessary to identify barriers of implementation and identify facilitating factors in the context in which they will be applied. In general, the process to define CPGs is costly and as such, it is indispensable to carefully strategize about the implementation process to be able to achieve the optimum use of often limited resources dedicated to these processes.
The implementation process is difficult and complex because of several key barriers. Researchers on this topic have developed a framework and have defined the frequent barriers to implementation in three main categories: 1) those related to physicians’ knowledge; 2) those related to physicians’ attitudes and 3) external barriers. Taking these barriers into consideration must be a key part of defining CPGs (5).
In summary, CPGs are an excellent tool to improve knowledge, reduce the inexplicable variability in clinical practice, incorporate novel technologies in health service provision based on evidence, improve health and outcomes and contribute to achieving increased health system efficiency.
1) Ministerio de Salud y Protección Social Guía Metodológica para la elaboración de Guías de Práctica Clínica con Evaluación Económica en el Sistema General de Seguridad Social en Salud Colombiano.
2) Instituto Mexicano del Seguro Social. Guías de Práctica clínica, una orientación para su desarrollo, Evaluación, Implementación Y. Dirección de Prestaciones Médicas, editor. Instituto Mexicano del Seguro Social; 2004. p. 1–44.
3) Homeira khoddam, Neda Mehrdad, Hamid Peyrovi, Alison L Kitson, Timothy J Schultz, and Asa Muntlin Athlin. Knowledge translation in health care: a concept analysis. Med J Islam Repub Iran. 2014; 28: 98.
4) Grol R. Successes and failures in the implementation of evidence-based guidelines for clinical practice. Med Care. 2001 Aug; 39(8 Suppl 2):II46-54
5) Florian Fischer,Kerstin Lange, Kristina Klose,Wolfgang Greiner, and Alexander Kraemer. Barriers and Strategies in Guideline Implementation—A Scoping Review. Healthcare (Basel). 2016 Sep; 4(3): 36