bluuebunny/crossref_metadata_2025 huggingface dataset:
P006 Updating Practice Guidelines
Authors: Paul Shekelle
Published: August 2013

A challenge facing all guideline developers is how to keep their guidelines up-to-date. The practice of using a fixed interval to update guidelines, such as every 3 or 5 years, may not be efficient in terms of resources or keep fast-moving guidelines sufficiently up-to-date. I will present a conceptual framework for considering when guidelines need updating, that includes periodic surveillance. Next I will present the results of a programme of surveillance of a large number of systematic reviews, a conceptually similar process. I will then relate our experience with implementing a programme of surveillance for guidelines produced by the American College of Physicians. I will conclude with thoughts and speculations about the future directions for surveillance and updating of guidelines
033 Using Rapid Reviews to Influence Guidance Development in the Emergency Department Setting
Authors: Ramachandran J
Published: August 2013

Background

Decision making within health care organisations often requires rapid response to emergent, controversial or high-impact issues affecting clinical and operational practices.

Context

CT imaging without oral contrast for patients admitted into the Emergency Department (ED) for abdominal/pelvic pain has been proposed as a viable option to reduce the risk of contrast-induced nephropathy and allergic reactions, as well as emergency room delays and overall length of stay (LOS) in the ED. A centralised evidence assessment unit within a large health care organisation was asked to conduct a rapid evidence review to inform the development of evidence-based guidance.

Description of Best Practice

A 5-step rapid review process was initiated, including: 1) Communicating with key stakeholders to determine relevant populations, interventions, comparisons, outcomes, timing and settings (PICOTS); 2) Conducting a comprehensive evidence search using a pre-established list of key databases and other sources to identify high-quality guidelines, systematic reviews and clinical trials evaluating the efficacy and diagnostic accuracy of conducting abdominal CT with and without oral contrast agents; 3) selecting and abstracting data from relevant studies; 4) evaluating and synthesising the literature; and 5) translating results for clinical/operational decision making. Findings of low- to moderate-quality evidence across outcomes, combined with operational and resource data, resulted in a decision not to implement the practice.

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

Coupled with expert input from knowledgeable clinicians and stakeholders, rapid evidence reviews can be critical to shaping evidence-based guidance in Emergency Department settings.
034 Do Models of Rapid Guideline Updates Fit Within the Current Australian Guideline Standards? An Example From the National Stroke Foundation Clinical Guidelines
Authors: Hill K , Wright L
Published: August 2013

Background

Clinical guideline recommendations are developed to assist health professionals to make evidence-based decisions. This is reliant on having the most up-to-date evidence available. The current Australian National Health and Medical Research Council (NHMRC) standards require guidelines to be updated within five years. An online process which provides transparency and enables timely changes/updates, such as the wiki platform developed and used by the Cancer Council of Australia (CCA), would provide a more useful platform to update guidelines but is currently not considered within the NHMRC standards.

Objectives

To evaluate if using the CCA wiki platform to update stroke guidelines would meet NHMRC standards.

Methods

We reviewed a potential CCA wiki platform (“wiki”) model against the existing NHMRC standards (2011) to determine compatibility and identify where changes to the wiki model might be required.

Results

The processes utilising the wiki were methodologically robust and were deemed to comply with 45/50 of the mandatory elements of the NHMRC standards with minor changes needed to comply with the other five elements. Difficulties arise predominantly due to the fact that the NHMRC standards are based on physically published guidelines.

Discussion

A model of rapid guideline updates utilising a wiki platform is able to accommodate robust methodology and meets most of the current Australian standards.
036 Development of A Statewide Guidelines Program Using The ADAPTE Framework
Authors: King V , Vandegriff S , Little A , Coffman D , Livingston C , Shaffer W , Gingerich J
Published: August 2013

Background

The legislature passed comprehensive health reform legislation in 2009 directing the state to “set standards for safe and effective care”, including development of “best practice guidelines and standards that can be uniformly applied across public and private health care”.

Objectives

Develop guideline methodology and guidelines for statewide clinicians and payers.

Methods

Employed ADAPTE framework for guideline development. Initial guidelines selected for development included three low back pain (LBP) topics: general evaluation and management of LBP (results described below), advanced imaging for LBP, and percutaneous interventions for LBP. Existing (seed) guidelines identified by searching 17 databases. Quality evaluated using modified AGREE II instrument. Multidisciplinary guideline development group selected and adapted seed guidelines. Stakeholder, peer review and public comments were solicited.

Results

Thirteen seed guidelines were identified and 10 met minimal inclusion criteria for LBP evaluation and management topic. Dual quality rating found five of good or fair quality. Final seed guideline selected based on quality and scope. Key recommendations were adopted for state Medicaid programme, including conservative and chiropractic care only in first month and no advanced imaging without clinical “red flags”. A consumer booklet was developed and distributed to consumer, provider, and payer groups. Over 2500 booklets were distributed, with over 11,000 page views on the website. The initial guideline process took over one year to complete.

Discussion

Starting a new multi-stakeholder guideline development programme requires substantial investments of methodological expertise, staff time, funds and political capital, but can substantially impact state health policy decisions.
037 Updating an Adapted CPG: When Is Enough Enough?
Authors: Harstall C , Moga C , Scott A , Taenzer P , Findlay T
Published: August 2013

Background

Within 2 years of releasing a low back pain clinical practice guideline (CPG), the Alberta Ambassador Guideline Adaptation Programme was required to update its adapted guideline. No guidance or ‘how to’ manuals were located.

Objectives

To develop a process for updating an adapted guideline. To expedite the process by determining which components can be removed without compromising rigour.

Methods

CPGs and systematic reviews published since the release of the CPG were identified and appraised, and discordant and new recommendations were tabulated. The Guideline Development Group (GDG) was surveyed to identify new interventions of interest. Evidence from systematic reviews was included for ‘do not know’ recommendations and new interventions.

Results

The original guideline had 50 recommendations, eight of which were in the ‘do not know’ category. This expanded to 85 recommendations in the update: 43 unchanged, 32 on GDG-nominated new interventions, and 10 revised. The updated CPG has 33 ‘do not know’ recommendations. One of the original eight ‘do not know’ recommendations was changed based on new evidence.

Discussion

The challenge of maintaining the integrity and high standards of the original guideline meant that the update consumed more time and resources than planned. Clearly, some components of the process can be jettisoned without jeopardising the methodological rigour and comprehensiveness of the final product.

Implications

The next update will be streamlined, including only new seed guidelines that meet the quality criteria of the modified AGREE and using systematic reviews to supplement the evidence base when there is discordance among recommendations.
038 Development of Multidisciplinary Symptom Management Tools Using The ADAPTE Approach
Authors: Harle I , Bak K , Molloy S , Green T
Published: August 2013

Background

Evidence-based tools for symptom management were developed to assist healthcare providers in comprehensive assessment and appropriate management of symptoms. These evidence-based tools consist of comprehensive guides-to-practice, quick reference pocket guides, algorithms and smart phone apps.

Objectives

The symptom management tools promote an interdisciplinary model of care that enables early identification and assessment of symptoms, appropriate documentation and communication regarding symptoms, optimal symptom management, and coordinated care throughout the illness trajectory. The tools are intended to be user-friendly, and are available in print, web and smart phone applications.

Methods

The tools were developed by an interdisciplinary panel of healthcare providers using the ADAPTE guideline adaptation approach. This included a literature search for recent guidelines and systematic reviews, guideline appraisal using the AGREE tool and selection, and in some instances modification, of recommendations. Expert feedback was obtained and subsequently appropriate revisions were made.

Results

The symptom management tools provide recommendations based on the best available evidence and expert consensus, for assessing, determining aetiology, diagnosing potential problems and for recommending non-pharmacological and pharmacological interventions.

Implications for Guideline Developers/Users

The ADAPTE approach offers a comprehensive and rapid process of developing evidence-based tools for the cancer patient population. Following the global trend of creating user-friendly clinical guidance, the guides-to-practice, quick reference pocket guides, algorithms and smart phone apps are an innovative set of tools that are accessible to a diverse group of care providers, in a manner that would suit the individual’s clinical needs.
P007 Keeping a programme of clinical guidelines up-to-date
Authors: Roberta James
Published: August 2013

Over the last 20 years, SIGN has published 132 guidelines. Of the 68 extant guidelines only 15 are under 3 years old. SIGN is committed to providing evidence based clinical practice guidelines to help accelerate the translation of new knowledge into action to meet our aim of reducing variations in practice, and improving patient-important outcomes.

SIGN has an established process of scoping, consulting on, prioritising and updating published guidelines. This process, however, is time and resource intensive and has been based heavily on the age of the guideline and the emergence of new evidence rather than on any real need from guideline users.

A full review of a guideline is equivalent to developing a new topic and takes 2–3 years. Some alternative approaches that SIGN has developed for keeping guidelines up to date in a more timely fashion include:

a selective update based only on those key questions underpinning a guideline that are shown to identify new evidence that would change recommendations. This process takes around 15 months and topics are scoped and prioritised;

a living guideline that is scoped and updated every year;

a small change affecting one or two recommendations that is highlighted by a guideline user or initiated by a change in licensing, legislation or local healthcare policy. This process takes around 6 months, is more reactive and driven by guideline user need but may only be applicable to newer guidelines.

This presentation will describe the risks, benefits, success and challenges in adopting these approaches. The key lessons learned include the need to:

clarify the need for the update

scope the evidence base and define the breadth of the remit

follow established processes and work within existing methodology

manage guideline development group expectations.
039 Guideline Developers’ Self-Perceptions of Adherence to and Intentions to Adhere to the IOM Standards
Authors: Jue J , Haskell L , Cunningham S , Nix M , Coates V
Published: August 2013

Background

The 2011 IOM report called for more rigorous and transparent development of guidelines. Compliance with the IOM Standards may be challenging for developers. Developer perception of their current adherence to the Standards gives insight into their understanding of them and the likelihood of adhering to them in the future.

Objectives

(1) Assess developers’ self-perceptions of adherence to the IOM standards (2) Assess developers’ intentions to adhere to the IOM standards.

Methods

This AHRQ funded work used a mixed-methods approach. We performed semi-structured telephone interviews and surveys to query developers about impressions of and intentions to implement the IOM standards in their CPGs. We also performed our own assessments of guidelines and compared them with developer self-ratings.

Results

Of 14 developers, 43% utilised a systematic review to underpin their guidelines, and 57% felt they would in the future. Funding sources were not disclosed by 46% of the developers. While 80% utilised an evidence rating scheme, fewer rated the recommendations. Notable differences between developer self-ratings and researcher assessments of adherence occurred in several areas.

Discussion

While some developers intend to improve processes to meet the Standards, others acknowledged they will not. Yet still others felt they already met the standards, but our assessment suggested a different estimation, revealing varying understanding among developers of the Standards.

Implications for Guideline Developers/Users

The IOM standards will help identify rigorous and transparent evidence-based guidelines, but will pose implementation challenges. Education of developers on the Standards and expectations around them will be critical.
040 Can Systems for Rating Evidence Quality and Recommendation Strength be Harmonised
Authors: Shiffman R
Published: August 2013

Background

In 2011 the IOM recommended that every guideline recommendation should be accompanied by an indication of Evidence Quality and Recommendation Strength and called for strategies to encourage harmonisation of development processes.

Objectives

To characterise the differences in systems for rating Evidence Quality and Recommendation Strength as a prelude to possible standardisation.

Methods

We examined 17 international, English-language guideline development systems to identify rating parameters and applied descriptive statistics. We also searched for conceptual linkages in the rating system descriptions and identified systems where Strength of Recommendation was stated as an Evidence Quality parameter.

Results

Rating systems were remarkably inconsistent in their application of category indicators—using letters, Arabic and Roman numerals and combinations. The modal and median number of Evidence Quality categories was 3 (range 0 to 10) and Recommendation Strength categories was 4 (range 0 to 6). 13/17 used randomised trials as indicators of highest quality evidence. 7 systems used “expert opinion,” 6 used “case reports” or “case series,” and 4 described “reasoning from first principles” to define lowest evidence quality. Definitions of intermediate levels varied considerably. 7 systems judged benefits and harms in deriving Recommendation Strength. In 7 rating systems, Strength of Recommendation was described entirely in terms of Evidence Quality.

Implication

There is considerable disagreement about the requisite granularity and definition of categories of Evidence Quality and Recommendation Strength. Application of the concept of Recommendation Strength consonant with the IOM standard is limited. A straightforward mapping of rating systems to one another is elusive.
043 Development and Implementation of National Standards For Spinal Cord Injury: A Partnership Between Accreditation Canada and the Rick Hansen Institute
Authors: Barrable B , Carpenter S , Noonan V , Thorogood N , Belanger L , Dvorak M
Published: August 2013

Background

Recent studies in Canada have identified variation in care delivery for acute and rehabilitation healthcare centres treating patients with spinal cord injury (SCI). The development of standards through an accreditation process ensures patients receive standards that are deemed important for their health condition. Accreditation Canada provides healthcare organisations with a rigorous and comprehensive accreditation process, and fosters quality improvement based on evidence-based standards and external peer review.

Context

To develop Accreditation Canada standards for SCI services across the continuum of care and provide an accountability framework to accelerate the implementation of best practices and improve quality of care for people living with SCI.

Description of Best Practice

Through a systematic review of literature and best evidence, standards for SCI care were defined for acute care management and rehabilitation. These standards were developed with input from an Advisory Committee with Canadian SCI experts and a web-based national consultation. The standards were piloted in 4 Canadian centres and received positive feedback. Suggestions are being integrated into the standards and in the next five years, the Rick Hansen Institute will work with centres in its network to accredit 50% or 16 centres using these standards.

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

Through providing a framework to evaluate quality and safety, Accreditation Canada and Rick Hansen Institute have an opportunity to improve the dissemination and implementation of best practices in SCI care that could serve as a model internationally.
048 Development of First Aid Guidelines For Recreational Athletes By Belgian Red Cross-Flanders
Authors: Pauwels N , Buck E De , Viroux P , Bellemans J , Meeusen R , Peers K , Verhelst K , Dieltjens T
Published: August 2013

Background

Belgian Red Cross-Flanders (BRCFl) is active in many fields including first aid training, for which BRCFl develops evidence-based guidelines according to AGREE II.

Objectives

Development of evidence-based recommendations for recreational athletes who perform one of 15 sport disciplines, defined by popularity, medical costs and injury risk in Flanders (Belgium). Initiatives concerning wording and accessibility were taken to develop implementable guidelines adapted for laypeople. These guidelines will also be used by the Flemish Government to update its information sources.

Methods

10 databases for guidelines, systematic reviews or individual studies were searched and draft recommendations were formulated based on the best current evidence. The quality of evidence was assessed using the GRADE approach. A guideline development group, including a multidisciplinary expert panel (co-authors PV, JB, RM and KP), discussed the draft recommendations while taking into account the evidence, and validated the final recommendations.

Results

32 systematic reviews and 2 guidelines that met the methodological criteria were identified as valuable source of studies. Additionally, 73 individual studies were included. The overall quality of the body of evidence varied from moderate to very low. Recommendations, written in active and explicit wording, were organised in a structure in order to be searchable via sports discipline, anatomical localisation, type of intervention, and injury.

Discussion

Preferences of the target group were taken into account when selecting the sport disciplines and when formulation the evidence-based recommendations.

Implications for Guideline Developers/Users

Involving the target population is an added value for developing an implementable evidence-based guideline.
050 Developing Evidence-Based Clinical Practice Guidelines for Primary Care Physiotherapy: A Local Initiative
Authors: Bernhardsson S , Larsson M
Published: August 2013

Background

In primary care physiotherapy in Sweden, there is a lack of evidence-based clinical practice guidelines to support clinicians and patients in clinical decision making. A local initiative to develop and implement evidence-based clinical practice guidelines for PTs in primary care was initiated by a regional health authority.

Objectives

To develop evidence-based clinical practice guidelines for physiotherapy treatment of low back pain, neck pain, and subacromial pain, for use in primary care physiotherapy in Sweden.

Methods

The guideline development was performed by a project team of five primary care physiotherapists in a systematic process that was guided by a 7-step guideline development model by Grol et al. We performed systematic database searches, critical appraisal of the evidence base using GRADE, and formulated evidence-based practice recommendations.

Results

The guideline format follows recommendations from AGREE II. The guidelines consist of a brief summary on the first page; a brief introduction to the topic with up-to-date information on definition of the condition, prevalence and prognosis; recommendations on patient management according to strength of evidence; a discussion section, and a detailed reference list. Detailed search strategy and search results, summaries of the body of evidence, recommended outcome measures, and patient information were provided in appendices to the guidelines.

Discussion

Rigorous guideline development methodology was considered important to get clinicians’ attention and approval - a requisite for regular use. Clinicians welcomed the initiative.

Implications for Guideline Developers

It is important for clinician acceptance that guidelines are brief, to the point and relevant.
051 Can We Automatically Produce Generic Decision Aids for the Clinical Encounter Directly from GRADE Guideline Recommendations? Experience from the Share-It Project
Authors: Agoritsas T , Brandt L , Heen A Anja , Kristiansen A , Alonso-Coello P , Akl E , Neumann I , Tikkinen K , Montor V , Guyatt G , Vandvik P
Published: August 2013

Background

Although decision aids (DA) can help to communicate evidence to patients, their production is time consuming, often not based on the best available evidence or rapidly outdated. Linking trustworthy guidelines and DA for shared-decision making could both overcome these limitations and enhance guideline dissemination.

Objectives

To test the feasibility of automatically translating any recommendations from GRADE guidelines into generic and interactive DA accessible on tablet computers for clinicians and their patients in the clinical encounter.

Methods

As part of the DECIDE project, we developed a framework for translating components of GRADE into DA, following the International Patient Decision Aid Standards. Using a recently published guideline, we implemented that framework in our MAGIC (Making Grade the Irresistible Choice) application – a prototype electronic guideline tool and publication platform that can automatically display recommendations in multilayered presentation formats.

Results

Our prototype was able to automatically translate a large number of GRADE recommendations and their supporting evidence into electronic and interactive DA. Preliminary results of user-testing in real patient-clinician interactions suggest that these DA can be used at the point of care to discuss estimates of treatment effects for patient relevant outcomes, confidence in estimates, burden of treatment, and cost issues.

Discussion

This study provides a proof-of-concept that components of GRADE recommendations can be interactively displayed in generic tools for interactive shared-decision making in a wide range of treatment alternatives.

Implications for Guideline Developers/Users

Our electronic DA offer promising opportunities to disseminate guidelines at the point of care.
052 Tools for Communicating Main Messages Conveyed By Clinical Practice Guidelines (CPGS) – Making Patient Resources User Friendly
Authors: Moga C , Angus D , Chojecki D , Harstall C , Moffatt J , Taenzer P
Published: August 2013

Background

Background The Alberta Ambassador Guideline Adaptation Programme developed two CPGs on the management of low back pain and headache in primary care. Various guideline companion documents were developed for patients.

Objectives

To review the process and outcomes of involving patients/public in the development of guideline resource documents.

Methods

Focus groups of different compositions and using various sampling strategies were called upon: self-selected members from national patient pain association (patient information sheets); members of the public who serve on a standing Lay Committee (patient information sheets, comic book); purposive recruitment by market research company (comic book). Participants answered questions related to the content, format, and presentation of patient resources using different interview methods.

Results

Discussion themes included wordiness of documents, language accessibility, use of logos, and trustworthiness. Multiple suggestions for improvements that were sensitive to the needs of participants were considered before publication of final products. The comic book was not published.

Discussion

Even though the focus group procedures varied, there was significant overlap and repetition in the feedback received on the same guideline resources. The patient focus group facilitated by a clinician engaged participants in discussions oriented to clinical issues. The comic book was considered to be a novel communication vehicle by clinicians but not so by public.

Implications for Guideline Developers/Users

Involving a motivated Lay Committee facilitated by someone not directly related to the project seems to be a valuable alternative to other focus groups of patients which may require more effort and resources.
056 Addressing Continuous Data For Participants Excluded From Trial Analysis: A Guide
Authors: Ebrahim S , Akl E , Mustafa R , Sun X , Walter S , Heels-Ansdell D , Alonso-Coello P , Johnston B , Guyatt G
Published: August 2013

Background

Guideline developers addressing quality of evidence commonly confront studies with missing data.

Objectives

To develop a framework for assessing risk of bias resulting from missing participant data for continuous outcomes in systematic reviews.

Methods

We developed a range of progressively more stringent imputation strategies to challenge the robustness of the pooled estimates. We applied our approach to two systematic reviews.

Results

We used 5 sources of data for imputing means for participants with missing data: [A] the best mean score among the intervention arms of included trials, [B] the best mean score among the control arms of included trials, [C] the mean score from the control arm of the same trial, [D] the worst mean score among the intervention arms of included trials, [E] the worst mean score among the control arms of included trials. Using these sources of data, we developed four progressively more stringent imputation strategies. In the first example review, effect estimates were diminished and lost significance as the strategies became more stringent, suggesting the need to rate down confidence in estimates of effect for risk of bias. In the second review, effect estimates maintained statistical significance using even the most stringent strategy, suggesting missing data does not undermine confidence in the results.

Discussion

Our approach provides rigorous yet reasonable and relatively simple, quantitative guidance that guideline developers can use for judging the impact of risk of bias as a result of missing participant data in systematic reviews of continuous outcomes.
057 Handling Trial Participants with Missing Data in Meta-Analyses Of Dichotomous Outcomes: Guidance for Systematic Reviewers
Authors: Akl E , Johnston B , Alonso-Coello P , Neumann I , Ebrahim S , Briel M , Cook D , Guyatt G
Published: August 2013

Background

Systematic reviewers including all randomised participants in their meta-analyses need to make assumptions about the outcomes of those with missing data.

Objectives

To provide systematic review authors with guidance on dealing with participants with missing data for dichotomous outcomes.

Methods

The authors used an iterative process of suggesting guidance and obtaining feedback to arrive at a proposed approach.

Results

For participants with missing data, systematic reviewers can use a range of plausible assumptions in the intervention and control arms. Extreme assumptions include ‘all’ or ‘none’ of the participants had an event, but these assumptions are not plausible. Less extreme assumptions may draw on the incidence rates within the trial (e.g., same incidence in the trial control arm) or in all trials included in the meta-analysis (e.g., highest incidence among control arms of all included trials). The primary meta-analysis may use either a complete case analysis or a plausible assumption. Sensitivity meta-analyses to test the robustness of the primary meta-analysis results should include extreme plausible assumptions. When the meta-analysis results are robust to extreme plausible assumptions, inferences are strengthened. Vulnerability to extreme plausible assumptions suggests rating down confidence in estimates of effect for risk of bias.

Conclusions

This guide proposes an approach to establishing confidence in estimates of effect when systematic reviewers are faced with missing participant data for binary dichotomous outcomes in randomised trials.
P009 Guideline Implementability: Learning from great thinkers like Picasso, the Dalai Lama and Anonymous
Authors: Melissa Brouwers
Published: August 2013

A tension faced in the guideline enterprise is finding the right balance between development, implementation and evaluation of recommendations. Are developers getting mired in the minutiae of creating the best guideline report? Are implementers choosing the best messages and strategies to optimise utilisation? Are evaluators assessing the most meaningful outcomes or the outcomes that are easiest to measure? Together, are these players in the guideline enterprise optimising what is known in their respective fields and the relationships among each other to create a system for success? In this presentation, we will turn for inspiration to some great thinkers, consider the research environment, and bring in real life examples to address these questions.
059 Nonrandomised Studies as a Source of Complementary, Sequential or Replacement Evidence for Randomised Controlled Trials in Systematic Reviews and Guidelines
Authors: Schünemann H , Tugwell P , Reeves B , Akl E , Santesso N , Spencer F , Shea B , Wells G , Helfand M
Published: August 2013

Background

The terms applicability, generalizability, external validity, transferability generally describe one overarching theme: can available research evidence be utilised to answer the health care questions at hand, ideally supported by a judgement about the degree of confidence in this utilisation. This concept has been called directness.

Objectives

To offer conceptual and practical guidance to those judging directness and using research evidence from non-randomised studies (NRS).

Methods

We used a literature review and feedback from participants of a workshop funded by the Agency for Healthcare Quality and Research and the Cochrane Collaboration.

Results

Guideline developers can use NRS as a source of complementary, sequential or replacement evidence for randomised controlled trials (RCTs) by focusing on judgements about the population, intervention, comparison and outcomes. They use NRS to complement judgements about inconsistency, the rationale and credibility of subgroup analysis, baseline risk estimates for the determination of absolute benefits and downsides, and the directness of surrogate outcomes. Authors use NRS as sequential evidence to provide evidence when the evidence from RCTs is insufficient (e.g. long-term harms). Use of evidence from NRS may also replace RCT evidence when RCTs provide indirect evidence but NRS provide overall higher quality, direct evidence. We developed a simple tool and algorithm to make judgements about indirectness more transparent.

Discussions

These judgements need to be made in the context of other quality of evidence domains.

Implications for Guideline Developers/Users

The transparency of the framework will support interaction with those making health care decision and policy.
060 Appraising Implementability During the Development Process Resulted in Guideline Revision
Authors: Veer S van der , Simon A , Weismann D , Lehner G , Coentrão L , Dongelmans D , Laecke S van , Lapauw B , Ortiz A , Schiller A , Tesar V , Nagler E
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 summarised 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/Users

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.
061 Guideline Implementability Appraisal (GLIA) in US National Guidelines
Authors: Chan W , Pearson T
Published: August 2013

Background

Guidelines must be implemented in order to impact health outcomes. Identifying and addressing potential barriers to implementation during guideline development can improve implementability.

Objectives

To describe the processes and results of embedding guideline implementability appraisal, into prominent US cardiovascular disease risk reduction guidelines.

Methods

The GuideLine Implementability Appraisal (GLIA) tool (Yale Center for Medical Informatics), was integrated into the guideline development processes of a US national-level organisation. A member of the Implementation Science Work Group (ISWG) with prior experience in GLIA appraisals trained the Guideline Development Teams (GDTs), early in the guideline development process, with the intent of raising awareness of potential barriers to implementation so they might be addressed during guideline development. Formal GLIA appraisals were performed on the drafts of the guideline reports, by members of the ISWG, as well as volunteers from outside the guideline programme. To minimise interference with timelines, appraisals were carried out and written reports returned to the GDTs within 2 weeks of release of the draft reports.

Results

A number of potential barriers to implementation were identified in the draft reports, such as: use of inexplicit terms in recommendation language, inconsistency of thresholds and terms used within a guideline, unclear applicability of assessment or treatment recommendations in specific subgroups. GDTs considered GLIA appraisal findings when they revised their reports and found the GLIA appraisals helpful in creating more implementable guidelines.

Implications for Guideline Developers/Users

GLIA training for GDTs, and formal use of the GLIA tool help produce more implementable guidelines.
063 Enhancing the Uptake of Clinical Practice Guidelines: The Development of a Guideline Implementability Tool (Guide-It)
Authors: Kastner M , Versloot J , Hayden L , Chatterjee A , Bhattacharyya O
Published: August 2013

Background

Guidelines have the potential to facilitate implementation of evidence into practice but this has not been consistently achieved. We developed a guideline implementability tool (GUIDE-IT), which can assess the implementability of guideline recommendations.

Objective

To determine if GUIDE-IT can improve the Language and Format of guideline recommendations.

Methods

Using a mixed-methods approach to develop GUIDE-IT, we conducted 1) a Realist Review of guideline factors influencing uptake, and used its results to build a conceptual model of guideline implementability; 2) qualitative interviews with 20 family physicians to determine factors influencing guideline uptake and to obtain input on tool design; 3) created a prototype and conducted validity assessments with experts in guideline development and human factors. GUIDE-IT was then pilot tested with the Canadian Diabetes/Paediatric Associations (CDA, CPS) to determine its potential for assessing the implementability of guideline recommendations.

Results

Pilot testing with CDA and CPS developers showed that factors across 4 sub-domains of Language (clarity, simplicity, specificity, and actionability) and 3 sub-domains of Format (presentation, components, and multiple versions) were applicable for modifying recommendations. GUIDE-IT was feasible to use by guideline developers to identify implementability problems and to improve recommendations.

Discussion

GUIDE-IT is based on a robust evidentiary base with the potential to improve guidelines. Next steps include evaluating GUIDE-IT in a controlled trial to determine its impact on end-user clinical decision making.

Implications for Guideline Developers/Users

GUIDE-IT has potential to be a practical tool for developers to improve the language and format of guideline recommendations.
066 How Are We Feeling Today? The Sensitivity of a Literature Search Filter for Patients’ Values and Preferences
Authors: Wessels M , Hielkema L
Published: August 2013

Background

The patient perspective in guideline development is of vital importance. To find out what this perspective entails, different methods may be considered, such as participation of patients or their representatives in guideline development groups or in focus group discussions, or by conducting patient surveys addressing specific problems and needs. In addition, a review of the literature in the early stages of guideline development can provide relevant information. Literature search filtres for patients’ perspectives and preferences applicable for Medline (OVID), PubMed, and Embase were developed and validated in 2012. The specificity was 98% but the sensitivity was only 90%.

Objectives

To verify the sensitivity of the filtres by means of a newly available ‘gold standard’.

Methods

We re-estimated the sensitivity of the search filtres by using the references of a recent Cochrane Review, Interventions for providers to promote a patient-centred approach in clinical consultations 2012;(12):CD003267, as a gold standard.

Results

The search filtres for patients’ values and preferences retrieved 72 (Medline (OVID/Pubmed) and 67 (Embase) titles, respectively, out of 73 references included in the Cochrane Review (mean sensitivity 96%).

Discussion

Applying filtres for patients’ perspectives and preferences retrieved almost all references. Minor adaptations to the Embase filtre were needed to enhance the sensitivity without compromising the specificity. Validation of filtres is an iterative process, illustrating that filtres are dynamic tools.

Implications for Guideline Developers/Users

Availability of a validated tool for retrieving literature on patients’ values and preferences can support integration of the patient perspective in guideline development.
An angiographic atlas of intracranial arterial diameters associated with cerebral aneurysms
Authors: Mocco J , Huston John , Fargen Kyle M , Torner James , Brown Robert D
Published: August 2013

Introduction

The successful treatment of intracranial aneurysms is dependent on a full understanding of the anatomic relationship of a given aneurysm to its parent artery(s) and nearby branches. Furthermore, new endovascular technologies are often limited by size constraints. Currently, there is no complete atlas describing diameters for each major intracranial arterial segment. We sought to obtain these data by performing a systematic analysis of selected cerebral angiography images from the International Study of Unruptured Intracranial Aneurysms (ISUIA).

Methods

Four hundred and forty-five patients with unruptured intracranial aneurysms from the ISUIA database were reviewed. Using previously described techniques, artery diameters were measured for all arteries involved in the aneurysm neck for each patient.

Results

Measurements were obtained from 695 different aneurysm-associated arterial segments among 445 patient angiograms (mean 1.6 measurements per aneurysm). Artery diameters, mean, median, SEM and IQRs based upon the different arterial segments are presented.

Conclusions

This angiographic almanac of aneurysm-associated intracranial arterial diameters may be of benefit in establishing standard norms through which devices, protocols and research aims may be developed.
The effect of acute dark chocolate consumption on carbohydrate metabolism and performance during rest and exercise
Authors: Stellingwerff Trent , Godin Jean-Philippe , Chou Chieh J. , Grathwohl Dominik , Ross Alastair B. , Cooper Karen A. , Williamson Gary , Actis-Goretta Lucas
Published: August 2013

Consumption of cocoa-enriched dark chocolate (DC) has been shown to alter glucose and insulin concentration during rest and exercise compared with cocoa-depleted control (CON). However, the impact of DC consumption on exercise metabolism and performance is uncertain. Therefore, we investigated carbohydrate metabolism via stable isotope tracer techniques during exercise after subjects ingested either DC or CON. Sixteen overnight-fasted male cyclists performed a single-blinded, randomized, crossover design trial, after consuming either DC or CON at 2 h prior to 2.5 h of steady-state (SS) exercise (∼45% peak oxygen uptake). This was followed by an ∼15-min time-trial (TT) and 60 min of recovery. [6,6-2H2]Glucose and [U-13C]glucose were infused during SS to assess glucose rate of appearance (Ra) and disappearance (Rd). After DC consumption, plasma (−)-glucose and insulin concentrations were significantly (p < 0.001) elevated throughout vs. CON. During SS, there was no difference in [6,6-2H2]glucose Ra between treatments, but towards the end of SS (last 60 min) there was a ∼16% decrease in Rd in DC vs. CON (p < 0.05). Accordingly, after DC there was an ∼18% significant decrease in plasma glucose oxidation (trial effect; p = 0.032), and an ∼15% increase in tracer-derived muscle glycogen utilization (p = 0.045) late during SS exercise. The higher blood glucose concentrations during exercise and recovery after DC consumption coincided with high concentrations of epicatechin and (or) theobromine. In summary, DC consumption altered muscle carbohydrate partitioning, between muscle glucose uptake and glycogen oxidation, but did not effect cycling TT performance.
Detrital zircon geochronology of Ediacaran to Cambrian deep-water strata of the Franklinian basin, northern Ellesmere Island, Nunavut: implications for regional stratigraphic correlations
Authors: Beranek Luke P. , Pease Victoria , Scott Robert A. , Thomsen Tonny B.
Published: August 2013

Enigmatic successions of deep-water strata referred to as the Nesmith beds and Grant Land Formation comprise the exposed base of the Franklinian passive margin sequence in northern Ellesmere Island, Nunavut. To test stratigraphic correlations with Ediacaran to Cambrian shallow-water strata of the Franklinian platform that are inferred by regional basin models, >500 detrital zircons from the Nesmith beds and Grant Land Formation were analyzed for sediment provenance analysis using laser ablation (LA–ICP–MS) and ion-microprobe (SIMS) methods. Samples of the Nesmith beds and Grant Land Formation are characterized by 1000–1300, 1600–2000, and 2500–2800 Ma detrital zircon age distributions and indicate provenance from rock assemblages of the Laurentian craton. In combination with regional stratigraphic constraints, these data support an Ediacaran to Cambrian paleodrainage model that features the Nesmith beds and Grant Land Formation as the offshore marine parts of a north- to northeast-directed depositional network. Proposed stratigraphic correlations between the Nesmith beds and Ediacaran platformal units of northern Greenland are consistent with the new detrital zircon results. Cambrian stratigraphic correlations within northern Ellesmere Island are permissive, but require further investigation because the Grant Land Formation provenance signatures agree with a third-order sedimentary system that has been homogenized by longshore current or gravity-flow processes, whereas coeval shallow-water strata yield a restricted range of detrital zircon ages and imply sources from local drainage areas or underlying rock units. The detrital zircon signatures of the Franklinian passive margin resemble those for the Cordilleran and Appalachian passive margins of Laurentia, which demonstrates the widespread recycling of North American rock assemblages after late Neoproterozoic continental rifting and breakup of supercontinent Rodinia.
Modeling the calcium and phosphate mineralization of American lobster cuticle
Authors: Kunkel Joseph G.
Published: August 2013

Bottom-up modeling of American lobster (Homarus americanus) cuticle explains architecture and function ab initio, from first principles, starting with synthesis of component polymers and progressively building composite structure that should explain observed properties. A top-down perspective decomposes the lobster cuticle starting at the top level of structural complexity and function aiming to descend to the finest detail. Both approaches aim to ultimately model the same cuticle structure. Current bottom-up models of the cuticle do not succeed in explaining key structural and functional detail identified by top-down approaches. Top-down identified structures and associated functions are valuable as bases for potential vulnerabilities to microbial attack. An immediate objective is to inform the bottom-up approach of top-down identified model components critical to cuticle function. Top-down features include detail of protein expression and mineral heterogeneity and their function in observed structures. This function-directed approach provides a better understanding of the distribution and roles of minerals in relation to their immediate cuticle environment. The top-down identified features can hopefully be included in ab initio models to improve our understanding of cuticle design.