Synthesising practice guidelines for the development of community-based exercise programmes after stroke

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Abstract

Background

Multiple guidelines are often available to inform practice in complex interventions. Guidance implementation may be facilitated if it is tailored to particular clinical issues and contexts. It should also aim to specify all elements of interventions that may mediate and modify effectiveness, including both their content and delivery. We conducted a focused synthesis of recommendations from stroke practice guidelines to produce a structured and comprehensive account to facilitate the development of community-based exercise programmes after stroke.

Methods

Published stroke clinical practice guidelines were searched for recommendations relevant to the content and delivery of community-based exercise interventions after stroke. These were synthesised using a framework based on target intervention outcomes, personal and programme proximal objectives, and recommended strategies.

Results

Nineteen guidelines were included in the synthesis (STRIDES; STroke Rehabilitation Intervention- Development Evidence Synthesis). Eight target outcomes, 14 proximal objectives, and 94 recommended strategies were identified. The synthesis was structured to present best practice recommendations in a format that could be used by intervention programme developers. It addresses both programme content and context, including personal factors, service standards and delivery issues. Some recommendations relating to content, and many relating to delivery and other contextual issues, were based on low level evidence or expert opinion. Where opinion varied, the synthesis indicates the range of best practice options suggested in guidelines.

Conclusions

The synthesis may assist implementation of best practice by providing a structured intervention description that focuses on a particular clinical application, addresses practical issues involved in programme development and provision, and illustrates the range of best-practice options available to users where robust evidence is lacking. The synthesis approach could be applied to other areas of stroke rehabilitation or to other complex interventions.

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Most cited references 34

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How can we improve guideline use? A conceptual framework of implementability

Anna R Gagliardi, Melissa C. Brouwers, Valerie Palda … (2011)

Background Guidelines continue to be underutilized, and a variety of strategies to improve their use have been suboptimal. Modifying guideline features represents an alternative, but untested way to promote their use. The purpose of this study was to identify and define features that facilitate guideline use, and examine whether and how they are included in current guidelines. Methods A guideline implementability framework was developed by reviewing the implementation science literature. We then examined whether guidelines included these, or additional implementability elements. Data were extracted from publicly available high quality guidelines reflecting primary and institutional care, reviewed independently by two individuals, who through discussion resolved conflicts, then by the research team. Results The final implementability framework included 22 elements organized in the domains of adaptability, usability, validity, applicability, communicability, accommodation, implementation, and evaluation. Data were extracted from 20 guidelines on the management of diabetes, hypertension, leg ulcer, and heart failure. Most contained a large volume of graded, narrative evidence, and tables featuring complementary clinical information. Few contained additional features that could improve guideline use. These included alternate versions for different users and purposes, summaries of evidence and recommendations, information to facilitate interaction with and involvement of patients, details of resource implications, and instructions on how to locally promote and monitor guideline use. There were no consistent trends by guideline topic. Conclusions Numerous opportunities were identified by which guidelines could be modified to support various types of decision making by different users. New governance structures may be required to accommodate development of guidelines with these features. Further research is needed to validate the proposed framework of guideline implementability, develop methods for preparing this information, and evaluate how inclusion of this information influences guideline use.

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An exploration of the factors that influence the implementation of evidence into practice.

Jo Rycroft-Malone, Gill Harvey, Kate Seers … (2004)

The challenges of implementing evidence-based practice are complex and varied. Against this background a framework has been developed to represent the multiple factors that may influence the implementation of evidence into practice. It is proposed that successful implementation is dependent upon the nature of the evidence being used, the quality of context, and, the type of facilitation required to enable the change process. This study sets out to scrutinize the elements of the framework through empirical enquiry. The aim of the study was to address the following questions: * What factors do practitioners identify as the most important in enabling implementation of evidence into practice? * What are the factors practitioners identify that mediate the implementation of evidence into practice? * Do the concepts of evidence, context and facilitation constitute the key elements of a framework for getting evidence into practice? The study was conducted in two phases. Phase 1: Exploratory focus groups (n = 2) were conducted to inform the development of an interview guide. This was used with individual key informants in case study sites. Phase 2: Two sites with on-going or recent implementation projects were studied. Within sites semi-structured interviews were conducted (n = 17). A number of key issues in relation to the implementation of evidence into practice emerged including: the nature and role of evidence, relevance and fit with organizational and practice issues, multi-professional relationships and collaboration, role of the project lead and resources. The results are discussed with reference to the wider literature and in relation to the on-going development of the framework. Crucially the growing body of evidence reveals that a focus on individual approaches to implementing evidence-based practice, such as skilling-up practitioners to appraise research evidence, will be ineffective by themselves. Key elements that require attention in implementing evidence into practice are presented and may provide a useful checklist for future implementation and evaluation projects.

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Development and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: the AGREE project.

(2003)

International interest in clinical practice guidelines has never been greater but many published guidelines do not meet the basic quality requirements. There have been renewed calls for validated criteria to assess the quality of guidelines. To develop and validate an international instrument for assessing the quality of the process and reporting of clinical practice guideline development. The instrument was developed through a multi-staged process of item generation, selection and scaling, field testing, and refinement procedures. 100 guidelines selected from 11 participating countries were evaluated independently by 194 appraisers with the instrument. Following refinement the instrument was further field tested on three guidelines per country by a new set of 70 appraisers. The final version of the instrument contained 23 items grouped into six quality domains with a 4 point Likert scale to score each item (scope and purpose, stakeholder involvement, rigour of development, clarity and presentation, applicability, editorial independence). 95% of appraisers found the instrument useful for assessing guidelines. Reliability was acceptable for most domains (Cronbach's alpha 0.64-0.88). Guidelines produced as part of an established guideline programme had significantly higher scores on editorial independence and, after the publication of a national policy, had significantly higher quality scores on rigour of development (p<0.005). Guidelines with technical documentation had higher scores on that domain (p<0.0001). This is the first time an appraisal instrument for clinical practice guidelines has been developed and tested internationally. The instrument is sensitive to differences in important aspects of guidelines and can be used consistently and easily by a wide range of professionals from different backgrounds. The adoption of common standards should improve the consistency and quality of the reporting of guideline development worldwide and provide a framework to encourage international comparison of clinical practice guidelines.

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Author and article information

Contributors

Leon Poltawski

Charles Abraham

Anne Forster

Victoria A Goodwin

Cherry Kilbride

Rod S Taylor

Sarah Dean

Journal

Journal ID (nlm-ta): Implement Sci

Journal ID (iso-abbrev): Implement Sci

Title: Implementation Science : IS

Publisher: BioMed Central

ISSN (Electronic): 1748-5908

Publication date Collection: 2013

Publication date (Electronic): 1 October 2013

Volume: 8

Page: 115

Affiliations

[1 ]University of Exeter Medical School, Veysey Building, Salmon Pool Lane, Exeter EX2 4SG, UK

[2 ]University of Exeter Medical School, St Luke’s Campus, Magdalen Rd, Exeter, UK

[3 ]Academic Unit of Elderly Care and Rehabilitation (University of Leeds), Bradford Institute for Health Research, Bradford Royal Infirmary, Duckworth Lane, Bradford, UK

[4 ]Centre for Research in Rehabilitation, Brunel University London, Mary Seacole Building, Kingston Lane, UB8 3PH, Middlesex, UK

Article

Publisher ID: 1748-5908-8-115

DOI: 10.1186/1748-5908-8-115

PMC ID: 3851241

PubMed ID: 24079302

SO-VID: 05e01ce1-0968-49be-874e-9bb7dc298ee8

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Synthesising practice guidelines for the development of community-based exercise programmes after stroke

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Abstract

Background

Methods

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Conclusions

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Stroke MRI

Most cited references 34

How can we improve guideline use? A conceptual framework of implementability

An exploration of the factors that influence the implementation of evidence into practice.

Development and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: the AGREE project.

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