(14/12/2001; supplementary material published 15 March 2002).
Crown copyright.
Product code: 26192.
Available online at http://www.dh.gov.uk/PublicationsAndStatistics/Publications/Publications PolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT ID=4002951&chk= 09Kkz1 [accessed 22 April 2006]. 2.
National Health Service (UK).
National Institute for Health and Clinical Excellence (NICE).
Endocrine, nutritional and metabolic.
Copyright 2006.
Available online at www.nice.org.uk/page .aspx?o=dg.endocrine [accessed 22 April 2006]. 3.
National Health Service (UK).
National Institute for Health and Clinical Excellence (NICE).
NICE Guideline: Type 2 diabetes, foot care: Appendix E.
NICE Foot Care Guidelines (Revision): Algorithm.
Available online at www.nice.org.uk/page.aspx?o=208094 [accessed 22 April 2006].
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37 Primary Care: Delivery/Translation of Guidelines into Practice Eva-Lisa Heinrichs and Michael Clark
INTRODUCTION The management of diabetes is consuming an increasingly significant portion of an already restricted health care budget.
As both the incidence and the prevalence of diabetes escalate, pres- sures to manage this pandemic cost-effectively will increase.1 Managing the diabetic foot and its complications has been presented as the most costly part of managing diabetes.2 To ensure that scarce resources achieve maximum health gain, health care policy strategies worldwide are shifting the main responsibility for prevention and treatment of chronic disease from secondary care to primary care.3 Consequently, this has been a key area of change in the management of diabetes.
The primary care sector is required to cope with increasing requirements of cost containment and efficiency whilst at the same time raising standards of care.
Clinical Practice Guidelines (CPGs) are by definition systematically developed recommen- dations to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.4 They are widely viewed as a summary of the best available research evidence together with recommendations for practitioners.5 It is universally acknowledged that evidence-based decision making and CPGs may serve as important tools to reduce variations in practice, contain costs and ultimately increase the effectiveness of clinical practice.6,7 Over the past several decades, there has been not only a remarkable growth in the development of CPGs, but also a greater appreciation of their value.5 Whilst the development of clinical guidelines regionally, nationally and internationally has increased substantially in recent years, less attention has been paid to guideline dis- semination and implementation, and it would be naı̈ve to suggest that just because guide- lines exist, their implementation automatically follows.8 In fact, large gaps exist between best practice and evidence in the implementation of CPGs, and we still lack in-depth knowl- edge of which factors are decisive in achieving changes, in which target groups and in which settings.9,10 The process of implementing CPGs has been likened to the process required to bring about organisational change.11,12 Many of the principles applicable to organisational change could
The Foot in Diabetes, 4th Edition. Edited by Andrew J.M. Boulton, Peter R. Cavanagh and Gerry Rayman. C 2006 John Wiley & Sons, Ltd. ISBN: 0-470-01504-7
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‘AGREE’: AN INSTRUMENT FOR APPRAISING GUIDELINES 405
therefore be applicable to CPGs implementation, and where relevant these principles have been applied in the discussion of the implementation process in this chapter.
CHOICE OF GUIDELINE Because of the wide variation in the quality of CPGs, it is important that users critically appraise available guidelines before implementing these in their practice setting.11,13 Not surprisingly, the quality of a CPG is an important variable that has been shown to affect its implementation.5 Guideline implementation continues to be a major challenge for those working in the health service, due in large part to the great number of practice guidelines available, some being more ‘evidence based’ than others.5,8,14 Thus, the first problem facing the primary care professional is the plethora of CPGs choices available, necessitating a suitable tool or means by which to make an optimal choice for the health care setting in question.
‘AGREE’: AN INSTRUMENT FOR APPRAISING GUIDELINES In 1998, the requirement for a tool to assist in guideline assessment and selection was recognised by international researchers and policymakers in Europe.
Subsequently, in 2001, an EU-funded collaboration resulted in the development of an instrument for appraising the quality and applicability of clinical guidelines , the so-called AGREE instrument. ‘AGREE’ stands for Appraisal of Guidelines Research and Evaluation.
The ongoing project’s aims are to improve medical knowledge and the health of the European population.
The main specific objective was to develop an appraisal instrument to assess clinical guidelines in order to promote the transfer of research results into clinical practice.
The AGREE instru- ment has subsequently become an internationally recognised generic tool for appraising the quality of CPGs.
It is designed to assess guidelines developed locally, regionally, nationally and internationally, and it can be applied to new guidelines as well as existing guidelines and updates to guidelines.15 The AGREE instrument can be used by guideline developers to assess whether their guide- lines are sound, by policymakers to help decide which guidelines could be recommended for use, by health care providers who wish to undertake an assessment before adopting the guide- line recommendations and finally by educators and teachers to help enhance critical appraisal skills amongst health care professionals.
Whilst the AGREE instrument assesses the likelihood that a guideline will achieve its intended result, it is important to note that it does not assess the impact on patient outcomes.15 The AGREE instrument consists of 23 items (criteria) organised into six sections or domains.
Each domain is intended to capture a separate guideline quality.
The six domains are as follows: r Scope and purpose; r Stakeholder involvement; r Rigour of development; r Clarity and presentation; r Applicability; r Editorial independence.
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406 PRIMARY CARE: DELIVERY/TRANSLATION OF GUIDELINES INTO PRACTICE
Table 37.1 An example of guidelines appraisal results using the AGREE instrument
Domain Item
Scope and purpose r The clarity of the overall objective r The expected health benefits to the specific clinical problem r Whether the target population is clearly described Stakeholder involvement r The information provided in the guidelines about the composition, discipline and relevant expertise of the guideline development group r The evidence that the patients’experiences and expectations of health care have been taken into consideration r Clear definition of target user(s) r Whether the guidelines have been pre-tested Rigour of development r The strategy used to search for evidence r The criteria for including/excluding evidence r The methods used to formulate the recommendations and how the final decisions were reached r The extent to which the guidelines consider health benefits, side effects and risks of the provided recommendations Clarity and presentation r Whether the recommendations are concrete and precise, as permitted by the evidence, or if the evidence is not clear-cut, whether this uncertainty is stated in the guidelines r Have the possible different options for screening, prevention, diagnosis or treatment of the clinical problem in question been covered? r Is it easy to find the most relevant recommendations? r Has additional material been provided to assist in the dissemination and implementation?
Applicability r Issues such as potential changes to the current organisation of care r Requirement for possible additional resources r Implications for the budget r Review criteria derived from the key recommendations have been defined so that adherence to the guidelines can be measured in case of implementation of the guideline in question Editorial independence r Independence of financial support provided for guidelines development r Declaration of conflict of interest on individual development group member level.