Infection Unit (Ward 42), Ninewells Hospital & Medical School, Dundee DD1 9SY, Scotland, UK
Keywords: evidence-based medicine, guidelines, quality of care
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Introduction |
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Evidence-based guidelines |
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Recommended guideline development methodology |
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There is clearly a need for a common, international, valid and transparent approach to the development of good clinical practice guidelines.8,9 The AGREE (Appraisal of Guidelines, Research and Evaluation for Europe; http://www.agreecollaboration.org) collaboration has developed a European agreed generic methodology to assess the quality of guidelines and the guideline development process. The Scottish Intercollegiate Guideline Network (SIGN, http://www.sign.ac.uk) has long adopted the majority of these criteria and has recently updated many aspects of SIGN methodology, which are consistent with the AGREE criteria. SIGN 50 is an excellent and commendable resource of the guideline process for any group wishing to embark upon this.8 All information is available on the websites.
A more recent comparison of 18 clinical guideline programmes has confirmed a significant improvement in guideline development throughout the world, but once again the data emphasize the importance of a continuing international effort to encourage worldwide adherence to this process.10 Guideline developers in the infection community throughout the world need to be encouraged to embrace this process and to consider these issues when planning future guidelines.
The current guidelines for hospital- and ventilator-associated pneumonia being undertaken by a working group of the British Society for Antimicrobial Chemotherapy (BSAC) appear to have taken these important considerations on board.
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Other approaches to guideline development |
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Consensus-based statements13 are popular and involve a broad-based panel who listen to the scientific data presented by experts, weigh the information and then compose a consensus statement that addresses a set of questions previously posed to the panel. Within this relatively small group, the interactions are such that some members will have a significant impact on the overall decisions. Other sources of bias include the type of questions set, the composition of the panel, the selection of the experts and the literature. Two examples of such a process are the consensus panel recommendations for managing serious candidaemia,14 and the synthesis of a consensus strategy for combating the prevention and control of antimicrobial-resistant microorganisms in hospital.15 The latter document is recognized as a good consensus statement: it aims to synthesize a strategy from expert opinion, experience and key existing evidence. It is explicit in its intention and development process and recognizes its inherent deficiencies. This document is acknowledged widely as pivotal in the building of an evidence-based approach to preventing antimicrobial resistance in hospitals. This is recognized in subsequent guidelines on the subject by the Society for Healthcare Epidemiology of America (SHEA) and the IDSA Joint Committee on the Prevention of Antimicrobial Resistance.16 However, this guideline approach, although valuable, does not follow the AGREE or SIGN methodology. When the AGREE instrument for appraising the quality of this guideline is applied (www.agreecollaboration.org, June 2001) a number of deficiencies in the areas of stakeholder involvement, rigour of development and clarity of presentation can be identified. This guideline is more in the form of a specialist but not systematic review, with only one table linking four recommendations to evidence. Greater adherence to AGREE methodology would be welcomed.
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Variability of quality of infection practice guidelines |
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Guideline implementation |
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Ultimately, regardless of the optimal implementation strategy, if we believe guidelines improve the clinical and cost effectiveness of healthcare,27 then we need to ensure good compliance using internal and external quality assurance systems within any organization. There is increasing study into the best way of achieving good adherence to guidelines recommendations, the basis of which are evidence based.29 This process is regarded as at least equal to, if not more important than, ensuring the successful impact of guidelines and should form an important component of the guideline document.
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Quality assurance and development of standards |
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Clinical standards primarily identify the essentials in the treatment of particular conditions if outcomes are to be optimized. Standards can be set at several levels: minimal, normative and exemplary.30 It is important to recognize what level of standards should be applied, as minimal standards are primarily aimed at promoting basic levels of care by identifying those areas or professionals who require remedial, or in rare cases punitive, action. Outcome-related standards are seen as the gold standard of performance measurement, but in reality they are difficult to capture, particularly in the short term.33,34 Increasingly, process or, to a lesser extent, structure measures are deemed more attractive, especially if they are linked through evidence to outcome.35 Indeed, guidelines or care pathways will outline intervention or processes of care that lead to a desired outcome.33 The timely (within 48 h of admission) administration of appropriate intravenous antibiotics for patients with severe CAP is regarded as a key quality indicator.36 This intervention is regarded as an important, validated, credible, consistent, simple and measurable process standard, based on evidence that is valued by clinicians, quality administrators and patients.36 A CAP audit in Tayside used this intervention as one of the key performance indicators in prospectively evaluating pneumonia care. This study revealed that a significant 39% of patients admitted with severe CAP did not receive antibiotics within the appropriate timeframe. Indeed, 29% did not receive intravenous antibiotics within 24 h of hospital admission.37 Poor performance on a process measure gives a clear indication of the remedial action that is required, and this can be linked to an incentive to bring about positive change. This audit in Dundee stimulated broad educational feedback and the development and implementation of a care pathway for CAP38 that will be subject to further evaluation (G. Barlow, personal communication). On the other hand, a commonly used crude outcome marker of death is more difficult to interpret as it is insensitive to the quality of healthcare received and can be influenced by a range of other factors.39 In our CAP audit38 compliance with the unit protocol appeared to be correlated with a reduction in mortality, but the association was by no means robust.
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Development of clinical standards in Scotland |
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Conclusion |
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Acknowledgements
I wish to thank all members of the SISS working group, especially Robert Laing and Ian Gould, for their interest and help with this work.
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Footnotes |
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References |
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