Clinical Practice Guidelines

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Clinical Practice Guidelines

• Research Education Perspectives

Susan Rappolt Department of Occupational Therapy
University of Toronto s.rappolt_at_utoronto.ca
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Clinical Practice Guidelines

• Definition
• A systematically developed statement designed to
  assist clinician and patient decisions about
  appropriate health care for specific clinical
  circumstances
• Field and Lohr, 1990

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• When written carefully, CPGs can offer guidance
  on treatment options based upon the established
  effectiveness of available therapeutic options
  (including no treatment), a patients individual
  clinical situation, minimization of harm, and
  cost.
• Green Piehl, 2003

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Evidence-Based Practice

• Evidence-based practice (EBP) is like a toolbox
  of methods available to the occupational therapy
  practitioner to aid clinical reasoning. The
  toolbox consists primarily of methods designed to
  integrate current and best evidence from research
  studies into the clinical reasoning process.
• Tickle-Degnen, 2000

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The EBP Toolbox

• Expert opinion, consensus panels
• Research papers (CAPS - critically appraised
  papers)
• Systematic Reviews (CATS critically appraised
  topics)
• Clinical practice guidelines (short-cuts to
  evidence)

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Decision Making in Client-Centred Practices

• Client evidence
• Research evidence
• Professional Expertise
• Knowledge of the context and resources
• Knowledge of own scope and skill level

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Accepted View of Professional Expertise in
Client-Centred Evidence-Based Practice

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Re-thinking Professional Expertise in
Client-Centred Evidence-Based Practice
O U T C O M E
Professional Role
Research Expertise
SPECIFIC CONTEXT OF PRACTICE

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Revised Role of Professional Expertise in
Client-Centred Evidence-Based Practice
Clinical Practice Guidelines

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Functions of CPGs

• For the Client
• Transparent treatment plans for informed
  collaborative decision-making
• Fosters best possible clinical practice
• Promotes best possible clinical outcomes

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Functions of CPGs

• For the Therapist
• Guide for practice
• Efficient short-cut to evidence
• Enhances validity of treatment approach for
  clients, regulators and payers
• Enhances credibility for marketing services

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Functions of CPGs

• For the Profession
• Formalizes a general practice process within a
  clinical domain
• Facilitates development of knowledge repertoire
  of profession
• Provides credibility in negotiations with payers

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Functions of CPGs

• Legal functions
• CPGs could be used with expert testimony to aid
  in determining the standard of care
• Expert testimony is used to determine the
  applicability of the CPG to the particular case.
• McDonagh, Lavis Sharpe, 2002

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Functions of CPGs

• For Payers
• Serve as guidelines for when to refer to OT
• Provide justification for allocation of resources
• Can be misused to constrain service utilization
  and control costs

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Functions of CPGs

• For Researchers
• CPGs provide a common protocol for studies of
  treatment effectiveness in improving client
  outcomes
• Results of studies of treatment effectiveness are
  used to validate or revise CPGs

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How are CPGs developed?

• Determine topic
• Assemble stakeholders
• Assemble and evaluate evidence
• Collaboratively produce guidelines
• Disseminate guidelines
• (full, abridged and consumer versions)
• Evaluate the impact of the guidelines
• Revise guideline as needed

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How to Evaluate a CPG

• Defined scope and purpose
• Stakeholder involvement
• Rigorous development
• Clear and well presented
• Applicability
• Editorial independence

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Effectiveness of CPGs in Improving Clinical
Outcomes

• some evidence that guideline-driven care can
  be effective in changing the process and outcome
  of care provided by professions allied to
  medicine.
• Thomas, Cullum, McColl, Rousseau, Soutter
  Steen, 2005

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Experiences of Other Professions with CPGs

• Physiotherapy
• Nursing
• Medicine

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Experiences of Other OT Organizations with CPGs

• American Association of Occupational Therapists
  (AOTA)
• National Association of Rheumatology Occupational
  Therapists (NAROT)
• CAOT Guidelines for Client-Centred Practice

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Clinical Practice Guidelines?

• What are the alternatives?