bluuebunny/crossref_metadata_2025 huggingface dataset:
Norovirus Genome Circularization and Efficient Replication Are Facilitated by Binding of PCBP2 and hnRNP A1
Authors: López-Manríquez Eduardo , Vashist Surender , Ureña Luis , Goodfellow Ian , Chavez Pedro , Mora-Heredia José Eduardo , Cancio-Lonches Clotilde , Garrido Efraín , Gutiérrez-Escolano Ana Lorena
Published: August 2013

Sequences and structures within the terminal genomic regions of plus-strand RNA viruses are targets for the binding of host proteins that modulate functions such as translation, RNA replication, and encapsidation. Using murine norovirus 1 (MNV-1), we describe the presence of long-range RNA-RNA interactions that were stabilized by cellular proteins. The proteins potentially responsible for the stabilization were selected based on their ability to bind the MNV-1 genome and/or having been reported to be involved in the stabilization of RNA-RNA interactions. Cell extracts were preincubated with antibodies against the selected proteins and used for coprecipitation reactions. Extracts treated with antibodies to poly(C) binding protein 2 (PCBP2) and heterogeneous nuclear ribonucleoprotein (hnRNP) A1 significantly reduced the 5′-3′ interaction. Both PCBP2 and hnRNP A1 recombinant proteins stabilized the 5′-3′ interactions and formed ribonucleoprotein complexes with the 5′ and 3′ ends of the MNV-1 genomic RNA. Mutations within the 3′ complementary sequences (CS) that disrupt the 5′-3′-end interactions resulted in a significant reduction of the viral titer, suggesting that the integrity of the 3′-end sequence and/or the lack of complementarity with the 5′ end is important for efficient virus replication. Small interfering RNA-mediated knockdown of PCBP2 or hnRNP A1 resulted in a reduction in virus yield, confirming a role for the observed interactions in efficient viral replication. PCBP2 and hnRNP A1 induced the circularization of MNV-1 RNA, as revealed by electron microscopy. This study provides evidence that PCBP2 and hnRNP A1 bind to the 5′ and 3′ ends of the MNV-1 viral RNA and contribute to RNA circularization, playing a role in the virus life cycle.
The effect of training doctors in communication skills on women’s satisfaction with doctor–woman relationship during labour and delivery: a stepped wedge cluster randomised trial in Damascus
Authors: Bashour Hyam N , Kanaan Mona , Kharouf Mayada H , Abdulsalam Asmaa A , Tabbaa Mohammed A , Cheikha Salah A
Published: August 2013

Objectives

To determine the effect of training residents in interpersonal and communication skills on women’s satisfaction with doctor–woman relationship in labour and delivery rooms.

Design

A stepped wedge cluster randomised trial.

Setting

4 tertiary care teaching maternity hospitals in Damascus, Syria.

Participants

2000 women who gave birth to a living baby in the four study hospitals and consented to participate in the intervention took part in the study. Women with difficult labour and high-risk pregnancies were excluded. All were interviewed at home after discharge.

Interventions

A specially designed training package in communication skills was delivered to all resident doctors at the four hospitals.

Primary outcome measures

The main outcome measure was women’s satisfaction with interpersonal relationships in labour and delivery rooms measured via a series of questions on a Likert scale modified from the Medical Interview Satisfaction Scale.

Results

At the individual level, the mean for the average satisfaction score was 3.23 (SD 0.72) of a possible score of 5 in the control group and 3.42 (SD 0.73) in the intervention group. Using generalised linear mixed models, we were unable to detect a difference between the mean for the average satisfaction score of women in the intervention arm and that of women in the control arm; the 95% CI associated with the effect of the intervention ranged from –0.08 to 0.15.

Conclusions

Despite slight changes in the observed residents’ communication skills, the training package in communication skills does not seem to be associated with higher satisfaction scores of women. This raises the question of whether training individuals without further structural changes in the delivery of care and without further reinforcement of the training can have an impact on improving the quality of doctor–patient communication.

Trial Registration Number

ISRCTN80243969
069 Facilitating Implementation of Guidelines for the Prevention of Vascular Disease In General Practice
Authors: Harris M , Litt J , Russell G , Mazza D , Lloyd J , Zwar N , Taylor R , Driel M Van , Mar C Del , Krastev Y , Parker S , Smith J
Published: August 2013

Background

Although evidence based guidelines have been developed and disseminated, up to a half of patients do not receive guideline based preventive care.

Objectives

This study aims to evaluate a model for the implementation of preventive care guidelines in general practice.

Methods

Following a development process for the intervention involving a mixed method study and a pilot carried out in three practices a cluster randomised controlled trial is being conducted in 31 practices across four states. The intervention involves training, preventive care audit, and visits from a facilitator based in the local primary care support organisation. The facilitator assists practices to review their clinical audit and implement a practice plan structured around the 5As to improve the reach and quality of preventive care. Quantitative and qualitative evaluation methods are being used to assess impact on planned change within the practice, recalled and recorded preventive care, and patient behaviours and risk factors for cardiovascular disease.

Results

Baseline data collection has been completed from practice staff and patients and the intervention is now complete. The recorded and patient recalled preventive care varied within and between practices resulting in a varied set of priorities for improvement. Early findings suggest that facilitation visits to review and plan improvements to the implementation of preventive guidelines are feasible, acceptable and can support organisational strategies to address gaps in care.

Discussion

Our results may provide a model for local primary care support organisations to assist practices to improve their quality of preventive care.
074 Implementation of Grade Methodology in Recommendation Development
Authors: Haynes J , Regidor D , Chan W
Published: August 2013

Background

We have been developing CPGs for use within our organisation since 2002. Our lengthy, text- based rationales were not widely read by guideline users. We created a decision support (rationale) table, based on GRADE methodology, and added a summary statement (basis of recommendation) to allow readers a concise and transparent snapshot of our justification for recommendation and strength.

Context

The rationale serves as a bridge between systematic review and recommendation, and provides users with a high-level justification for a recommendation. The basis of recommendation (BoR) summarises the 4 GRADE domains of strength of recommendation and how they are integrated to derive the final recommendation and strength. The BoR serves to: •Provide information to the Guideline Development Team and frontline clinicians to facilitate discussion, consensus and aid clinical decision-making. •Provide a structured, standardised portal into more detailed information in the CPG.

Description of Best Practice

We follow GRADE’s 2-level designation of recommendation strength (strong/weak), and developed standardised recommendation language to align with recommendation strength. We considered two approaches to derive the final recommendation strength, finally settling on an approach that allows flexible weighting of the contribution of each domain to recommendation strength. With this approach, in special circumstances, a strong recommendation may be given in the absence of a high-level of certainty. We plan to provide direct links from the CPG to our electronic medical record’s decision support tools.

Lessons for Guideline Developers, Adaptors, Implementers, and/or Users

A concise and targeted rationale helps clinicians understand how evidence is used to develop clinical practice recommendations.
075 The Use of GRADE Methods in the World Health Organization (Who) Public Health Guidelines (PHG): Distribution of Strength of Recommendations and Confidence in Estimates of Effect
Authors: Elias P , Norris S , Brito J , Stoltzfus R , Bero L , Djulbegovic B , Neumann I , Montiori V , Guyatt G
Published: August 2013

Background

A perception exists that expert guideline panellists are sometimes reluctant to offer weak/conditional/contingent recommendations. GRADE guidance warns against strong recommendations when confidence in estimates of effect is low or very low (low or very low quality evidence), suggesting that such recommendations may seldom be justified.

Objectives

To characterise the distribution of strength of recommendations and confidence in estimates of effect in WHO guidelines that have used the GRADE approach and graded strength of recommendations and confidence in effect estimates.

Methods

We reviewed guidelines listed in the WHO guidelines database as of November 2012. We identified those that use GRADE and, in these guidelines, examined the distributions of strong and weak and associated confidence in estimates of effect (high, moderate, low, and very low).

Results

We identified 116 WHO guidelines; 48 (41.3%) referred to GRADE methods, and 43 (37%) utilised GRADE and provided both a strength of recommendation and confidence in estimates grading. These 43 guidelines included 456 recommendations, of which 290 (63.6%) were strong and 166 (36.4%) were conditional/weak. Of the 290 strong recommendations, 97 (33.4%) were based on evidence warranting low confidence in estimates of effect and 63 (21.7%) on evidence warranting only very low confidence.

Discussion

Strong recommendations based on low or very low confidence in effect estimates are very frequently made in WHO guidelines. Further study to determine the reasons for such recommendations is warranted.

Implications for Guideline Developers/Users

Guideline authors should provide a clear, compelling rationale for any strong recommendations based on low confidence estimates.
077 Development of an Evidence to Recommendation Table for Guideline Users
Authors: Rigau D , Neumann I , Sanabria A , Kristiansen A , Brandt L , Vandvik P , Alonso-Coello P
Published: August 2013

Background

The DECIDE project aims to improve the dissemination of recommendations using GRADE. Clinical practice guidelines (CPGs) summary tables do not include all the relevant factors for moving from evidence to recommendations: quality of the evidence, balance of benefits and harms, values and preferences and cost.

Objectives

Development of an optimal presentation table to inform about the evidence to recommendation (EtR) process to healthcare professionals.

Methods

Iterative process including brainstorming and design, user testing with semi-structured interviews, and stakeholder consultation. We analysed the feedback to our initial prototype, defined barriers and facilitators, and generated alternative formats.

Results

The table was well rated overall by users. It was found useful to understand in more depth the rationale of the recommendation and of use for teaching sessions. Some users found it potentially useful for shared decision making while others did not find it useful at the point of care. Most frustrations came from misunderstanding some terms, the general purpose of the table or the GRADE system.

Discussion

This EtR table could be a useful tool for CPGs users and tabulates all the relevant information beneath the EtR process. We are preparing a second round of user testing and stakeholder consultation, and will present a new format at the conference.

Implications for GL Developers and Users

This table will provide users a concise summary of the factors influencing the EtR process. The efficiency of including an EtR table in real CPGs needs to be further evaluated.
078 What Does an Evidence-Based Guideline Committee Do When There is Insufficient Evidence to Make a Recommendation
Authors: Wilson L , Robinson K
Published: August 2013

Background

When guidelines are called evidence-based (EBGs) the implication is that there was a transparent and systematic assessment of evidence. However, evidence is often insufficient to draw conclusions. In these cases, what do guideline committees do?

Objectives

To estimate the proportion of recommendations in a set of EBGs for which there was insufficient evidence and to determine the implications for the guidelines.

Methods

We reviewed EBGs developed by the Cystic Fibrosis Foundation and classified each recommendation as developed using evidence (i.e., graded) or consensus.

Results

We identified 143 recommendations from 7 EBGs. More than half of the recommendations were consensus-based (61%) while 39% were evidence-based. Of those classified as evidence-based, 41% were non-recommendations; these were statements where the committee felt unable to make a recommendation for or against a particular action (insufficient grade). The consensus-based recommendations included 11% adopted from other organisations; only a quarter of the consensus-based statements were developed using an apparent formal method.

Discussion

Committee members often feel compelled to provide recommendations for the community even in the face of insufficient evidence. This limits the transparency of the EBG. Further research is needed to determine the potential implications for implementation.

Implications for Guideline Developers/Users

Guidance is needed for guideline developers on best practices for if or when to consider consensus-based recommendations and how to develop such recommendations. The guidelines should clearly outline choices, such as when a consensus-based recommendation was made versus not making a recommendation, and the methods used.
084 PLUGGED-IN (Providing Likeable and Understandable Guidelines using GRADE in the EMR with Direct links to Individual patient data) Phase 2
Authors: Brandt L , Elde T , Agoritsas T , Guyatt G , Kristiansen A , Alonso-Coello P , Akl E , Meerpohl J , Vandvik P
Published: August 2013

Background

Traditional clinical decision support systems in Electronic Medical Records (EMR) use algorithms with inclusion/exclusion criteria to provide direction to clinicians. Improved systems for developing trustworthy guidelines (e.g. GRADE,) typically include many weak recommendations unsuited for clear inclusion/exclusion criteria, and in which the right decision varies from patient to patient. Through PLUGGED-IN phase 1 we developed a conceptual framework and a guideline authoring/publication platform to allow use of trustworthy guidelines directly as decision support in EMRs, not dependent on traditional algorithms or reproduction of the content. Our framework is based on a multilayered guideline presentation format developed in DECIDE.

Objectives

To implement and test our novel approach to decision support where relevant patient specific information is shown alongside evidence based recommendations in EMRs.

Methods

We used a web guideline published through the MAGIC (Making Grade the Irresistible Choice) application, which allowed our EMR partner to make use of its structured content, ontology-coded clinical questions and recommendation-specific EMR elements.

Results

The EMR system was able to interact with the guideline, suggest relevant recommendations displayed along with relevant patient specific information (lab tests, measurements, medications), and offer these to facilitate direct ordering. We will show real examples and live products.

Discussion

Results suggest we can offer a complementary approach to traditional algorithm-based systems that is compatible with a large number of EMRs.

Implications for Guideline Developers/Users

PLUGGED-IN provides a model for direct use of guidelines as decision support in EMRs.
085 Implementing a Knowledge Application Program for Anxiety and Depression in Community-Based Primary Mental Health Care: The Clinical Decision Support Component
Authors: Roberge P , Fournier L , Brouillet H , Benoit A
Published: August 2013

Background

We developed a knowledge application programme to support the improvement of the organisation and delivery of care for anxiety and depressive disorders in community-based primary mental health care teams (CMHTs) in Quebec (Canada). The programme is based on the Chronic Care Model, including a Decision Support component, and the PARiHS framework.

Objectives

1- To implement and evaluate a knowledge application programme, 2- to explore barriers and facilitators associated with the implementation of Decision Support strategies, particularly the uptake of clinical practice guidelines.

Methods

The design is a mixed-methods prospective multiple case study, with data drawn from the two phases of the project (2008-2010; 2011-2014). Multidisciplinary local working committees in the six CMHTs were required to develop and implement local quality improvement plans with the support of a knowledge broker.

Results

While we observed barriers and facilitators at the clinician level in terms of knowledge (e.g familiarity) and attitudes (e.g. applicability, agreement), contextual factors (e.g resources, access) also played an important role in the uptake of clinical practice guidelines into the six local CHMTs.

Discussion

Decision Support is a central component of the Chronic Care Model that aims to promote clinical care that is consistent with scientific evidence.

Implications

The uptake of evidence in primary care is a complex process that requires careful consideration of the context in which innovations are introduced, and our assessment of barriers and facilitators can be relevant to other primary health care organisations seeking to increase the uptake of anxiety and depression clinical guidelines.
086 Guidelines adaptation in Low and Middle Income Countries (LMIC): Results and lessons learnt from an 8-year-capacity building (CB) experience in Argentina (2005–2012)
Authors: Esandi M , Luca M De , Ortiz Z
Published: August 2013

Background

Capacity building (CB) is an essential element for guideline adaptation in the context of LMIC.

Objectives

To describe the approach and results from a CB process for guidelines adaptation implemented by the National Academy of Medicine (NAM) in Argentina between 2005 and 2012.

Methods

The CB process is described on the basis of the matrix of capacity-building strategies. Duration, objectives, entities targeted and results through the different stages of the CB process are provided.

Results

The CB process has been supported on a “learning by doing” approach, and comprised 2 stages: a local capacity development stage (2005–2008) and a knowledge transfer (KT) stage (2008–2012). As a result of the 1st stage, 120 health professionals were involved during the adaptation process; 3 guidelines were produced and a guide to adapt guidelines was published. KT started in 2008 and was initially performed through e-learning courses targeted to individuals. In 2009, a strategy based on continuous online support through a virtual campus and workshops and targeted to institutions was adopted. Four institutions were involved: 1 did not progress; 1 completed the whole process and published an evidence-based guideline and 2 are on-going.

Implications for Guideline Developers/Users

In the context of LMIC, CB processes based on the “learning by doing” approach and focused to institutions seem to be more appropriate although challenging: not only technical capacities have to be built, but also those related to human resources management, group-working and use of Internet resources. Different level of achievement of these capacities could explain the results observed alongside the CB process implemented by NAM.
088 Cohort of Clinical Practice Guidelines from the Spanish National Guideline Programme: A Survival Analysis
Authors: García L Martínez , Sanabria A , David R , Barajas L , Fontecha P Díaz del Campo , Sabadell M Estrada , Ikobaltzeta I Etxeandia , Álvarez E García , González A Louro , Fernandez F Salcedo , Trujill M , Alonso-Coello P
Published: August 2013

Background

Clinical Practice Guidelines (CPGs) recommendations need to be updated to maintain their validity.

Objectives

To provide empirical estimates of the average time after which CPGs recommendations become obsolete.

Methods

We developed a strategy to assess the validity of CPG recommendations, which included assessing their validity by surveying clinical experts, updating the literature search, screening references by pertinence and matching them with recommendations, and identifying pertinent, relevant and key references, and potential changes in each recommendation. A convenience sample of four CPGs was selected. We piloted our strategy in 20% of the recommendations from these CPGs (feasibility test) and we estimated our sample size. We performed a survival analysis and considered a CPG outdated when more than 20% of recommendations needed to be updated.

Results

The four CPGs included 250 recommendations. A total of 39.133 (range 3.343–14.784) references were identified in the exhaustive literature search in a time frame of 3–5 years. The feasibility test identified 16 key references updating 8 recommendations. The number of recommendations required for the study was 113. A total of 674 references were marked as pertinent to these recommendations.

Discussion

We developed a rigorous, replicable evaluation strategy to assess the validity of recommendations and estimate CPG obsolescence. Full final results will be present at the GIN meeting.

Implications for Guideline Developers/Users

Our work is relevant for guideline developers because it provides information about the expected validity of CPGs recommendations.
093 Measurement Instrument for Determinants of Innovations (MIDI)
Authors: Fleuren M , Paulussen T , Dommelen P van , Buuren S van
Published: August 2013

Background

In 2002, we developed a list of 60 potential relevant determinants that are critical for a successful implementation of innovations in health care, such as guidelines. This list was a result of a review of empirical studies and a Delphi study among implementation experts. Since 2002, we used the list in eight empirical studies concerning the implementation of guidelines/programs.

Objectives

The development of a generic measurement instrument for the assessment of determinants of implementation of innovations.

Methods

In each study, a similar method was used to measure implementation of the guideline/program as well as the determinants. The information of the eight empirical studies were combined into one data set. Missing values in the final data set were replaced by plausible values using multiple imputation. We assessed which determinants ‘predict’ the implementation: separately and in combination with each other. In addition, 22 implementation experts commented on the results of the meta-analyses.

Results

An instrument with 29 determinants was established; 7 are related to the guideline/programme itself; 11 to the user; 11 to the organisation and socio-political context.

Discussion

This instrument is to be used before or after a guideline is introduced in order to gain insight into critical determinants that need to be targeted in order to improve implementation.

Implications for Guideline Developers/Users

Since 7 determinants are related to the innovation itself (e.g. clear procedures) developers should take these into account when developing a guideline.
P002 A Summary of the Methods That the Alexandria Centre for Evidence-Based Clinical Practice Guidelines (CEBCPGs) uses to produce Clinical Practice Guidelines for the Healthcare Quality Directorate of Alexandria University Hospitals and Healthcare Sectors in Alexandria
Authors: Amer Y , Elzalabany M , Omar T , Ibrahim A
Published: August 2013

Background

The CEBCPGs produces CPGs on high priority health topics to establish recommendations based on best evidence. The authors summarise the main methods used in adaptation and implementation of these CPGs.

Objectives

The aim of this work was to promote simplicity, avoid redundancy and decrease delay in the process of CPG adaptation.

Methods

Part 1) Cross-sectional/ or retrospective study and assessment of the current situation of practice in selected healthcare settings to identify/select high priority health topic(s) and to justify the need for producing a CPG for this topic(s) and expected benefit and outcome for its implementation; Part 2) consists of the Methodology for CPGs adaptation, based on an adaptation of The ADAPTE Process developed by the ADAPTE Collaboration.

Results

Three main ADAPTE steps were identified as cornerstones of the process and another two steps in the assessment module were replaced by the AGREE Domains scores.

Implications for Guideline Developers/Adapters/Users

1. Health Topics for CPG Adaptation & Implementation should be selected based on Cross-sectional study/surveys for local Healthcare Professionals. 2. Adaptation of CPGs as a valid alternative tode novodevelopment has many benefits for resource utilisation and unifying practice. 3. The ADAPTE process is that it is adaptable to local context and resources. 3. Successful CPGs Implementation Strategies; i)For Practitioners: Implementation tools designed to facilitate behavioural/practice changes (e.g. Posters & Brochures of Clinical algorithms & Flow charts), Educational material, Educational meetings (e.g. conferences, lectures & workshops) and Local Clinical Champions; ii) For Patients/Carers: Education materials and meetings.
P013 Using networks to facilitate international guideline implementation: allergic rhinitis as an example
Authors: Bousquet Jean
Published: August 2013

Allergic rhinitis and asthma represent global health problems for all age groups. Asthma and rhinitis frequently co-exist in the same subjects. Patients, clinicians and other health care professionals are confronted with various treatment choices for the management of allergic rhinitis. This contributes to considerable variation in clinical practice and, worldwide, patients, clinicians and other health care professionals are faced with uncertainty about the relative merits and downsides of the various treatment options. The outcomes of an expert workshop (ARIA: Allergic Rhinitis and its Impact on Asthma) held at the World Health Organization (WHO) in December 1999 were published in 2001. The ARIA workshop report was innovative in:

Proposing a new AR classification using persistence and severity of symptoms (mild/moderate-severe and intermittent/persistent).

Promoting the concept of co-morbidities in asthma and rhinitis as a key factor for patients’ management.

Developing guidelines in collaboration with relevant stakeholders including primary care physicians, and patients.

Including experts from developed and developing countries.

Adopting an evidence-based approach for the first time in guidelines on rhinitis.

Initiating global implementation among health care professionals and patients.

As new evidence about treatments for allergic rhinitis emerged, the methodology for guideline development changed. ARIA went with the times and move, after an evidence based update in 2008, to adopting the GRADE approach with its 2010 update. ARIA is disseminated and implemented in over 50 countries of the world. The Pocket Guide has been translated in 52 languages and it is arguably one of the most disseminated guidelines. We will report on the opportunities for international dissemination that evolved over time, report on how we accomplished it and how new media, such as Apps, can be used to facilitate the process of dissemination, using ARIA as an example.
P038 Completing the PDCA circle for guidelines within one organisation
Authors: Stemkens D , Aben K , Osanto S , Groot J de , Verhoof E
Published: August 2013

Background

Our organisation is closely involved in the continuous process of developing, implementing and evaluating (evidence based) guidelines for oncological and palliative care. we use the unique combination of data from our national cancer registry, our knowledge and experience as well as the knowledge and experience of medical professionals and patient representatives available through national and regional networks. As part of this process, each evidence based guideline is evaluated with the objective: 1. to get insight in the adherence; 2. to get insight in possible bottlenecks for the implementation in daily practice; 3. to stimulate further implementation by giving feedback.

Description of Best Practice

The case of the guideline renal cell carcinoma will be presented. This includes the following steps: 1. selection of recommendations (based on the new guideline) by the guideline working group; 2. definition of indicators; 3. registration by trained registration staff of our national cancer registry; 4. analysis of the results; 5. presentation of results to professionals; 6. specific promotion of expertise and skills to further implement the guideline.

Lessons for Guideline Developers/Users

The combination of development, implementation and evaluation of guidelines ’in one hand’ offers special opportunities for quality improvement. During guideline development it already becomes clear which recommendations will need extra attention during implementation. These recommendations are very interesting to evaluate, so that the feedback about these recommendations can help the professionals to further implement the guideline.
P060 When Evidence is Weak or Insufficient, how can we Produce Guidance that is Trustworthy?
Authors: Lewis S Zelman , Ornelas J , Casey K
Published: August 2013

Background

The GuideLine Implementability Appraisal (GLIA) instrument has been suggested for identifying potentially remediable implementability issues during the guideline development process.

Objective

To explore to what extent using GLIA during the development process would result in guideline revision before publication.

Methods

The development process of the European hyponatremia guideline -coordinated by European Renal Best Practice - was our study context. Using the GLIA web-tool, eleven clinicians and methodologists from eight countries individually appraised 27 guideline statements. In a face-to-face consensus meeting, four GLIA panelists and one guideline development group (GDG) representative summarized potential implementability issues. The GDG discussed these issues, and revised the guideline if deemed necessary.

Results

We identified 33 issues; the GDG accepted 26 as potentially hampering implementability. This resulted in statement reformulation with (n=5) and without (n=10) influencing clinical content, adding or (re)moving entire statements (n=8), and adding information to tables or rationales (n=3). The majority of issues declined by the GDG (n=7) addressed clinical situations that were covered elsewhere in the guideline or were considered to be uncommon.

Discussion

Using GLIA during the development process resulted in a revised guideline. We felt that GDG representation in the consensus meeting optimize our appraisal process.

Implications for Guideline Developers

Guideline organizations may want to consider incorporating GLIA into their development process. This may raise GDGs’ awareness of potential implementability issues, and allow revision of the guideline accordingly prior to publication. Future research should explore the effect of GLIA-based revisions on implementability as assessed by guideline users.
P066 What kinds of changes did the publication of large-scale RCTs related to HPV testing lead to in cervical cancer screening guidelines?
Authors: Hamashima C , Kishi T
Published: August 2013

Objectives

Although the mortality of cervical cancer has decreased in developed countries, HPV testing has been anticipated as a new technique for cervical cancer screening. Since 2009, three RCTs have reported final outcomes that evaluated reduction of the mortality of cervical cancer or of the incidence of invasive cancer. Changes in the assessment of HPV testing in guidelines, evidence reports, and statements are examined.

Methods

A search was performed from January 2010 to January 2012 using MEDLINE, the GIN library, and the National Guidelines Clearinghouse to identify guidelines, evidence reports, and statements that evaluated HPV testing. Additional reports recommended by experts were also included as needed. Assessments of HPV testing and related evidence were compared.

Results

Eight guidelines and two evidence reports matching our criteria were identified. When HPV testing was recommended and introduced, it was based on the results of studies conducted in the respective countries. The methods of HPV testing were different, because interpretations of the results of the RCTs were different among these guidelines and reports.

Discussion

Although new techniques are expected to be introduced early in comminutes, long follow-up is needed to evaluate efficacy. In such situations, studies conducted in respective countries are often considered to represent favourable results. To resolve this problem, a modelling approach could be used, but the appropriateness of such an approach for guideline development needs to be investigated.

Implication for Guideline Developers

To evaluate the efficacy of a new technique, modelling studies should be standardised for guideline development.
P071 Guidelines For Guideline Developers: A Systematic Review Of Grading Systems For Medical Tests
Authors: Gopalakrishna G , Langendam M , Scholten R , Bossuyt P , Leeflang M
Published: August 2013

Background

Development of guidelines for medical tests are challenging given the indirectness of evidence on patient outcomes. We compared grading systems for medical tests in terms of basic guideline quality requirements and on how they use indirect evidence.

Methods

We used a systematic search to identify grading systems specific to medical tests in PubMed, professional guideline websites and handsearching back references of key articles. Using the AGREE instrument as a starting point, we defined two sets of characteristics to describe these systems: process and methodological ones. Process characteristics were features related to the guideline development process. Methodological characteristics were defined as features relating to how evidence is gathered, appraised and recommendations development. Data was extracted in duplicate and differences resolved through discussion.

Results

Twelve grading systems were included. Process characteristics least often addressed were whether the system was piloted (3/12) and funder information (3/12). Methodologically, developing a clinical scenario, care pathway and/or analytical framework, having explicit criteria for appraising and linking indirect evidence, and having explicit methodologies for translating evidence into recommendations were least frequently addressed. Five systems at most addressed these to varying degrees of completeness.

Implications for Guideline Developers

There is a need for standardisation of basic guideline features a grading system should address. No one system adequately addressed the complexity of gathering, assessing and linking different bodies of evidence. There is a need for critical appraisal of these features in each system and for targeted user testing among guideline developers.
P092 Does The Addition Of Symbols Make Guidelines Recommendations Clearer? Results From An Online Survey
Authors: Nast A , Rosumeck S , Jacobs A , Sporbeck B
Published: August 2013

Background

A recent study has shown that the perceived meaning of wordings in recommendations such as “should” or “must” can vary among guideline users. In addition to the wordings, many guidelines use graphic symbols such as arrows or smileys to support their recommendations.

Objectives

To determine whether such symbols influence the perceived meaning of the recommendations or may help to reduce variation in the perception of the meaning between different guidelines’ users.

Methods

With the help of an online-survey, using a visual analogue scale (0–100), participating physicians from different specialties were asked to express their perceived levels of obligation when confronted with different guidelines recommendations in combination with different symbols.

Results

269 physicians participated, the addition of a “single arrow” or “double arrow” to the recommendation did not lead to relevant changes in the perceived obligation expressed by the recommendation (median: soll/shall: 83 vs. 87; “sollte/should”: 77 vs. 78). In comparison to the prior study, variations in the interpretation of typical guideline wordings were not reduced if symbols were used additionally.

Discussion

In this study, the impact of symbols on the understanding of a guidelines recommendation was limited. Important methodological limitations apply but this study questions the impact of symbols to clarify a recommendation’s message. However, visual aids are likely to be very important for users to help to identify recommendations within larger text document and therefore make guidelines easier to use and implement.
P111 A Workflow Checklist for Improving Management of the Guideline Development Process
Authors: Haller M , Nagler E , van der Veer S , Nistor I , Bolignano D , Van Biesen W
Published: August 2013

Background

Keeping track of progress and meeting deadlines can be difficult for organisations that simultaneously develop multiple guidelines involving multiple systematic review teams.

Objectives

To improve planning, organising and managing of guideline development projects by creating a standardised workflow checklist.

Methods

In a one-day meeting, the five guideline development methodologists, the chairman and the editorial assistant identified the main steps involved in the guideline development process. For each step, we identified specific tasks and ordered them chronologically. All decisions were made based on group consensus. The identified steps and tasks formed the basic elements of the workflow checklist.

Results

We identified the need for two separate checklists per guideline development project; one for overall workflow and one for each clinical question covered by the guideline. The overall guideline development workflow checklist comprised 42 tasks organised in 11 sequential steps, including items such as topic selection, composition of the guideline development group, and framing the questions. For each clinical question we identified 27 tasks organised in 8 sequential steps, excluding steps already covered by the overall workflow.

Discussion

This workflow checklist represents a first step in developing a standardised project management strategy to improve efficient management of the guideline development process. Further development of this tool involves selecting appropriate software for practical implementation applicable not only for our own means but also for those of other groups.

Implications for Guideline Developers/Users

We believe developing a standardised workflow checklist will improve efficient management of guideline development and allows transparent and up-to-date communication of its progress.
P129 Estimating Service Capacity for Commissioning an Anticoagulation Service in Line with NICE Guidance in the NHS, England
Authors: Moran D , Griffiths P , Moore V
Published: August 2013

Background

Improving quality, patient outcomes and cost effectiveness is an assumed aim of health and social care commissioning. A key aspect for commissioners in the planning phase of the commissioning cycle for an anticoagulation service, in line with NICE guidance, is the ability to estimate the level of service that will be required in order to appropriately commission or decommission services.

Objectives

Establish the level of integration of information, alongside clinical and management knowledge, required to successfully calculate appropriate service levels when commissioning or decommissioning an anticoagulation services in the NHS.

Methods

A critical appraisal of clinical research studies, epidemiological data, NHS activity data and other information was carried out in combination with clinical and NHS management oversight to inform an estimate of service levels for an anticoagulation service. A systematic literature search of 3 electronic databases, Medline, Embase and Cochrane was carried out. Routinely collected activity data was reviewed through a sample of GP practice systems for primary care information and hospital episode statistics for secondary care information. Healthcare professionals and commissioners with a specialty or interest in an anticoagulation service were consulted.

Results

Interim results suggest integration of multiple information sources in combination with clinical and management knowledge produces more robust estimates of service levels for an anticoagulation service.

Discussion

The accuracy, and therefore the utility of estimates of service levels for an anticoagulation service will be improved by information linkage, and by using intelligence from multiple sources. This approach could be applied to estimating service levels for other commissioned services.
P149 Development Of Evidence Based Guidelines For The Treatment Of Seizures And Epilepsy
Authors: Ott U , Hegmann K , Thiese M , Passey D , Caughey W , Carter Z
Published: August 2013

Background

Seizures in the past year affect approximately 20% of patients with epilepsy. Vehicle crashes are also well associated with epilepsy. Different requirements for drivers with epilepsy exist across state, regional and national jurisdictions. However, a widely accepted threshold for risk of crash of 1% is common in safety sensitive positions.

Objectives

To develop evidence based guidelines for the treatment and return to work/driving for those with a history of seizures and epilepsy.

Methods

A panel of 5 experts developed a set of specific questions regarding the prevalence of seizures and risks of recurrence. A research team developed a search strategy which included utilisation of specific search terms for each question. A systematic literature review was performed. Databases searched included Pubmed, EBSCO and Google Scholar.

Results

246 research articles were reviewed. For individuals with a history of a single, unprovoked seizure, evidence supports a minimum of 82.02 months (6.8 years) off anti-seizure medication and seizure free. A worker with a history of seizures should have a minimum of 10 years off anti-seizure medications and seizure free prior to returning to a safety sensitive position.

Discussion

These analyses provide guidance for the treatment of seizures and epilepsy and return to safety sensitive positions. Implications The breadth of safety sensitive jobs includes fork lifting driving, truck drivers, bus drivers, overhead crane operations, and the airline industry.
P156 Clinical Practice Guidelines In Paediatrics In The Czech Republic
Authors: Klikova K , Licenik R , Mihal V
Published: August 2013

Background

High quality clinical practice guidelines in paediatrics (CPGP) should be developed with standard and rigour methods. There are specialty societies in the Czech Republic developing guidelines of variable quality using different methods of development, adaptation, implementation and evaluation

Objectives

The aim of this study was to analyse the methods of development, adaptation, dissemination, implementation and evaluation of Czech CPGP.

Methods

The database of all CPGP was developed in 2011 and updated on a regular basis. The three types of specialty societies were decided: 1. Paediatric and neonatology societies 2. Other specialty societies developing CPGP 3. Specialty societies developing guidelines with relevant recommendation for paediatric care. The search and analysis of open resources were made to find the information about guideline methodology. Questionnaire survey to get the missing information was made.

Results

There are 113 specialty medical societies in the Czech Republic. 31 societies developed 140 CPGS. 31% developed by paediatric and neonatology societies, 51% by other societies and 18% by societies developing CPGs with some paediatric recommendations. The questionnaire survey is ongoing.

Discussion

The methods of development CPGP in the Czech Republic is of low quality. There are no explicit strategies for dissemination, implementation and evaluation.

Implications for Guideline Developers/Users

The methods of guideline development need be standardised and should be of highest possible quality. There is already high quality methodology in the Czech Republic developed by National Reference Centre, which has been using by different specialty societies and could be used for CPGP.
P162 Rigor of Development Of Clinical Practice Guidelines In Dentistry
Authors: Brignardello-Petersen R , Carrasco-Labra A , AbdelAziz A , Hartshorne J , Azarpazhooh A
Published: August 2013

Background

Some reports have shown the varying quality of clinical practice guidelines (CPGs), but this aspect has not been explored in the field of dentistry. With a growing number of guidelines in dentistry being published every year, and an increase in dentist’s interest to inform their practice with such documents, it is relevant to learn whether their development process has been appropriate.

Objectives

To assess the rigour of development of evidence-based CPG’s in dentistry.

Methods

We searched Pubmed, EMBASE, and the National Guideline Clearinghouse among others. We included all evidence-based CPGs with explicit clinical recommendations, published since 2004 in English. Two independent evaluators assessed the guidelines using the “Rigour of development” domain of AGREE II.

Results

A total of 73 CPGs were assessed. The mean score of the rigour of development domain across all guidelines was 34.54% (SD=19.18%). The items that scored the lowest were the description of a procedure for updating the guideline and the strengths and limitations of the evidence; whereas the items best rated were the explicit link between the evidence supporting the recommendations and the pondering of benefits, harms and risk for formulating the recommendations.

Discussion

CPGs aim to support clinical decision-making, and thus they can impact the quality of health-care. Thus, the rigour in their development is a relevant aspect to consider. There is a lot of room for improvement in this regard in CPGs in dentistry.

Implications for Guideline Developers

Guideline developers in dentistry should enhance the methodology when creating new guidelines or updating existing ones.