Dissemination and implementation of clinical practice guidelines: a longitudinal, mixed-methods evaluation of the Canadian Task Force on Preventive Health Care’s knowledge translation efforts
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- RE: Collaboration & Democratization of Guidelines Possible Key to Optimal ImplementationDoreen M. Rabi [MD MSc FRCPC], Diana Sherifali [RN PhD CDE] and Stella S. Daskalopulou [MD PhD FRCPC]Posted on: 20 September 2023
- Posted on: (20 September 2023)Page navigation anchor for RE: Collaboration & Democratization of Guidelines Possible Key to Optimal ImplementationRE: Collaboration & Democratization of Guidelines Possible Key to Optimal Implementation
- Doreen M. Rabi [MD MSc FRCPC], Clinician Researcher, Professor, Departments of Medicine, Cardiac Science and Community Health Sciences, Cumming School of Medicine, University of Cal
- Other Contributors:
- Diana Sherifali, Clinical Researcher
- Stella S. Daskalopulou, Clinician Scientist
We would like to congratulate Dr. Fahim and their team for this important work.
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A key finding of this work was that misalignment of clinical guidance with patient priorities and preferences limited successful implementation. This finding resonates with our experiences as guideline authors. In speaking publicly, we have felt or heard that some recommendations are seen as unhelpful or out of touch with the challenges of primary care practice. Intensive blood pressure lowering recommendations, for example, while supported by strong evidence (1, 2), were met with immediate concern that wide implementation was going to be very difficult. The lived experience of frontline clinicians was that older adults experienced hypotension and electrolyte abnormalities frequently with anti-hypertensive medication intensification and that use of these guidelines would be resource intensive and potentially unsafe.
Guidelines should be developed in collaboration with patients as partnered development processes produce guidance people need and foster mutual understanding and respect for diverse lived experiences (3). This sort of collaboration, however, is uncommon and inconsistently executed (4). While the CTFPHC has articulated a desire and need to ensure patient partnership going forward, the experiences of patients whose care was informed by their cancer screening guidelines were not examined in this study. Shared decision-making (which the CTFPHC recommends) cannot be evalu...We would like to congratulate Dr. Fahim and their team for this important work.
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A key finding of this work was that misalignment of clinical guidance with patient priorities and preferences limited successful implementation. This finding resonates with our experiences as guideline authors. In speaking publicly, we have felt or heard that some recommendations are seen as unhelpful or out of touch with the challenges of primary care practice. Intensive blood pressure lowering recommendations, for example, while supported by strong evidence (1, 2), were met with immediate concern that wide implementation was going to be very difficult. The lived experience of frontline clinicians was that older adults experienced hypotension and electrolyte abnormalities frequently with anti-hypertensive medication intensification and that use of these guidelines would be resource intensive and potentially unsafe.
Guidelines should be developed in collaboration with patients as partnered development processes produce guidance people need and foster mutual understanding and respect for diverse lived experiences (3). This sort of collaboration, however, is uncommon and inconsistently executed (4). While the CTFPHC has articulated a desire and need to ensure patient partnership going forward, the experiences of patients whose care was informed by their cancer screening guidelines were not examined in this study. Shared decision-making (which the CTFPHC recommends) cannot be evaluated by examining clinician experiences alone.
We appreciate the recommendations of this study’s participants on the importance of “branding” the CTFPHC guidelines. The participants suggested a need to differentiate the CTFPHC guidelines from other guidance products, and that limited conflict of interest (COI) and rigorous methodology should be emphasized as distinguishing characteristics of the CTFPHC.
With respect, it is reductive and possibly inaccurate, to presume CTFPHC is better at COI management simply because they have a strict no financial COI policy. Conflicts are complex and can be indirect. Professional conflicts or ‘confluence’ must also be considered and the prestige of being a member of a guideline panel (CTFPHC included) is noteworthy. For example, members of may receive professional benefits (e.g., promotion and related increases in salaries) for their volunteerism. Removing guidelines from the academic meritocratic system is what is needed and the only way to really mitigate the risk of COI- financial and professional. The key deliverable for most guideline development groups is a peer-reviewed publication. However, guidelines ought to be centred on the users and not the authors or a brand. Ownership should be a collective endeavour, and thus dissemination can be built around the user. Guidelines need to be democratized- not canonized- to be trusted.
Again, we are very grateful to this team for doing such elegant, challenging, and thought-provoking work.Competing Interests: None declared.References
- 1. Leung AA, Daskalopoulou SS, Dasgupta K, et al; Hypertension Canada. Hypertension Canada’s 2017 guidelines for diagnosis, risk assessment, prevention, and treatment of hypertension in adults. Can J Cardiol. 2017; 33:557–576.
- 2. Wright JT, Williamson JD, Whelton PK, et al; SPRINT Research Group. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015; 373:2103–2116
- 3. Armstrong MJ, Mullins CD, Gronseth GS, Gagliardi AR. Impact of patient involvement on clinical practice guideline development: a parallel group study. Implement Sci. 2018 Apr 16;13(1):55.
- 4. Bryant EA, Scott AM, Greenwood H, Thomas R. Patient and public involvement in the development of clinical practice guidelines: a scoping review. BMJ Open. 2022 Sep 28;12(9):e055428
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