Dissemination and adaptation strategies customized for trustworthy practice guidelines using the GRADE framework

Abstract

Background Over the last few decades, the world of health care has seen a growing productivity, amassing an increasing amount of research evidence. Clinical practice guidelines incorporating not only the best available research evidence, but also clinical experience and patient preferences can provide a potential solution to the resulting message fatigue. Unfortunately they often suffer from subpar rigor of development, applicability and usability. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework provides a comprehensive system for development of trustworthy guidelines. GRADE has yet to provide specific solutions on how to communicate and disseminate recommendations to narrow the evidence to practice gap. This thesis aimed to 1) create and test a novel guideline presentation format (paper I & II), 2) develop and evaluate a new adaptation framework (paper III), and 3) apply the new strategies for dissemination and adaptation through development of a Norwegian guideline for antithrombotic therapy (paper IV). Material and methods This project is part of the research and innovation program MAGIC (MAking GRADE the Irresistible Choice), which applies a holistic approach to improving the development, dissemination and updating of guidelines. In a collaborative effort between the MAGIC organization and the DECIDE (Developing and Evaluating Communication Strategies to Support Informed Decisions and Practice Based on Evidence) project funded by the European Union, we applied a mixedmethods approach to develop and test new guideline presentation formats. We performed multiple cycles of brainstorming, sketching and usability testing (paper I). We undertook a randomized, controlled trial by use of clickers to vet our new format against a standard format, examining the outcomes of preference, perceived understanding, usefulness and intended clinical action (paper II). Informed by current standards for trustworthy guidelines and the widely applied ADAPTE framework, an international group of clinicians and experts in health research methodology devised an adaptation framework for evaluating and modifying individual recommendations (paper III). We applied and evaluated the strategies for dissemination and adaptation by developing a guideline for antithrombotic therapy (paper IV). We elected the 9th iteration of the American College of Chest Physicians (ACCP) Evidence-based Guidelines for Antithrombotic Therapy (AT9) as the source guideline due to its currency and stringent application of GRADE. Results We created a new digitally structured, multilayered presentation format for communicating recommendations to end-user clinicians. Clinicians are presented with the recommendations first, together with the strength of the recommendation. By accessing the recommendation, the clinician can delve into deeper layers of relevant information, such as the key information (certainty and magnitude of the net benefit of the considered intervention, patient preferences and values, resources and other feasibility considerations), rationale, practical information, evidence summary tables, references and adaptation disclaimers. We randomized 181 practicing physicians in five countries to either the multilayered format or a current standard presentation format. 72% of the participants preferred the multilayered format and a majority expressed that they found recommendations useful. Both during usability testing and in the randomized trial we observed common struggles in comprehending key concepts of uncertainty that could be partly alleviated by clearer phrasing and short explanations. We developed, evaluated and revised a five-step adaptation process and accompanying taxonomy for modifying recommendations tailored to the GRADE methodology. The steps include 1) planning, 2) individual assessment, 3) modifications, 4) publication and 5) evaluation. We applied the five-step adaptation process with 46 recruited clinicians adapting the original AT9 guideline to the Norwegian setting, rewriting the recommendations in the multilayered format. We excluded 30 (9%), modified 131 (39%) of the original recommendations and developed eight new recommendations. The most common reason for modification was feasibility issues (e.g. availability of drugs). In November 2013, we published 249 adapted and updated recommendations on the web-based authoring and publication platform (MAGICapp). The adapted guideline can be accessed on any electronic device at www.nsth.no. Conclusion In conclusion, we developed, iteratively revised, tested and demonstrated superior preference for a novel, multilayered guideline presentation format. We also developed a five-step adaptation process and accompanying taxonomy and demonstrated the feasibility of both strategies by applying them in the making of a Norwegian antithrombotic guideline.