Evidence‐basing for quality improvement; bringing clinical practice guidelines closer to their promise of improving care practices

Abstract

Background: Clinical practice guidelines (CPGs) have become central to efforts to change clinical practice and improve the quality of health care. Despite growing attention for rigorous development methodologies, it remains unclear what contribution CPGs make to quality improvement. Aim: This mixed methods study examines guideline quality in relation to the availability of certain types of evidence and reflects on the implications of CPGs' promise to improve the quality of care practices. Methods: The quality of 62 CPGs was assessed with the Appraisal of Guidelines, Research, and Evaluation (AGREE) instrument. Findings were discussed in 19 followup interviews to examine how different quality aspects were considered during development. Results: The AGREE assessment showed that while some quality criteria were met, CPGs have limited coverage of domains such as stakeholder involvement and applicability, which generally lack a 'strong' evidence base (e.g., randomized controlled trials [RCT]). Qualitative findings uncovered barriers that impede the consolidation of evidence-based guideline development and quality improvement including guideline scoping based on the patient-intervention-comparison-outcome (PICO) question format and a lack of clinical experts involved in evidence appraisal. Developers used workarounds to include quality considerations that lack a strong base of RCT evidence, which often ended up in separate documents or appendices. Conclusion: Findings suggest that CPGs mostly fail to integrate different epistemologies needed to inform the quality improvement of clinical practice. To bring CPGs closer to their promise, guideline scoping should maintain a focus on the most pertinent quality issues that point developers toward the most fitting knowledge for the question at hand, stretching beyond the PICO format. To address questions that lack a strong evidence base, developers actually need to appeal to other sources of knowledge, such

Creating an (ethical) epistemic space for the normalization of clinical and “real food” oral immunotherapy for food allergy

“…Additionally, in line with the suggestions of Moleman et al (2022), it is helpful and perhaps necessary going forward in the development of CPGs, to emphasize and explicate the applicability of clinical practice guidelines to their domains of care and practice. Whilst the formal and laudable integration of both patient and ethical principles vis-à-vis the MCA approach responds to the calls by sociologists and medical professionals, the uptake and legitimacy of this type of guideline could acquire further usefulness and credibility through explicit discussions of and visions for how it can and will inform actual clinical practice.…”

“…As mentioned at the outset of this article, both sociologists and medical professionals acknowledge and lament the absence of “other” evidence in the development of clinical practice guidelines. Guideline developers and sociologists have referred to the inadequacies of the “scientization” of guideline development (Moleman et al, 2022). These groups have also noted there is a lack of methodologies available to assess, weigh and integrate “other” types of evidence.…”

Linking Costs and Quality in Healthcare: Towards Sustainable Healthcare Systems Comment on "Hospitals Bending the Cost Curve With Increased Quality: A Scoping Review Into Integrated Hospital Strategies"

“…Endnotes [1] Note, however, that some definitions of quality, like the one from the IoM, do implicitly include costs, by mentioning efficiency as part of quality. More common understandings, however, would refer to effectiveness, safety and patient-centredness, sometimes including timeliness and accessibility.…”

“…Costs and quality have only incidentally been brought together in public outcries of healthcare leaders that the best care for individual clients is no longer possible. Such outcries underscore the urgency of the policy problem, stressing the need to studying the issues of costs and quality in tandem [1] .…”

“…In the aftermath of the publication of the now famous ‘To Err is Human’ report from the Institute of Medicine at the turn of the century (1999), healthcare organizations, professional bodies and healthcare regulators have attempted to improve quality of care through safety regulations (ie, procedures for medical errors and near incidents), standardizing care and – more recently – developing all sorts of initiatives to foster personalized healthcare delivery. While there is an abundance of literature within fields like Health Technology Assessment on the cost-effectiveness of interventions, quality instruments like guidelines are often developed without taking costst into account 1 and even instruments which are meant to be integrated, like value-based healthcare, often focus on quality alone. 2 The separation of ‘costs’ and ‘quality of care’ in organization or system-wide policies is surprising, however, in the light of contemporary debates on healthcare sustainability.…”