Practice Guidelines March 13, 2007
Posted by rickbarth in Uncategorized.trackback
I have not followed the world of “practice guidelines” very carefully, except to note that this has been a focus of the evidence-based practice work at Washington University’s Brown School of Social Work, especially Aaron Rosen and Enola Proctor. I know that this has become integrated into their curriculum, as well, and students are expected to know what resources there are that indicate best practice.
I recently came across this very intriguing website, the National Guildeline Clearhinghouse, which is a initiative of the Agency for Healthcare Research and Quality(AHRQ) that has practice guidelines for many health conditions, including behavioral health assessments and treatments (222 guidelines in all). I encourage your review. (I welcome comments from those who know more about this topic of implementing guidelines than I do.) The website is at http://www.guideline.gov/about/about.aspx. The behavioral treatments are at http://www.guideline.gov/browse/browsemode.aspx?node=7542&type=2
Thanks for this post - I was not aware of this resource. My only familiarity with Practice Guidelines was through the American Professional Society on the Abuse of Children (APSAC). http://apsac.fmhi.usf.edu/publications/publication_practice_guid.asp
The efforts by APSAC to develop and disseminate practice guidelines was a focus of that organization about ten years ago but although there was strong interest by APSAC members, there were few subjects where there was either research or consensus about the best ways to intervene in specific child abuse and neglect situations. Over the years, there were at least 10 other topics where committees drafted specific guidelines but due to disagreement or controversy, they were never published. Perhaps we are at a stage of development where this kind of endeavor would be more feasible today.
It will be interesting to follow the efforts of the Campbell Collaboration - - as more systemtatic reviews of research are published, the next step should be the development of practice guidelines based on these reviews.
http://www.campbellcollaboration.org/index.asp
I had a chance to do some reading on the topic of practice guidelines for the literature review that I had to do for Dr. DeForge’s class last semester. I was interested in the utilization of research in practice and he suggested that I look at practice guidelines in health, which has an extensive body of research, with a number of studies using RCTs to examine the dissemination and implementation of specific practice guidelines for health care practitioners (nurses, doctors, etc.). I was also familiar with the AHRQ website since I have been working recently with a colleague, David Introcaso, a health policy analyst at ASPE, he was formerly at ARHQ, and very familiar with these issues.
So - below are some highlights from my readings and conversations with David about this topic:
-Not surprisingly, there are a complex set of factors that must be considered which impact the dissemination and utilization of practice guidelines. In terms of practitioner attitudes/ beliefs/ experiences with guidelines, there was a general appreciation and interest in using the guidelines. However, there were often a number of challenges such as the lack of resources in organizations to access the literature and workload issues which presented barriers to the use of the guidelines. In addition, staff also indicated a desire for more training on how to concretely use the research more effectively.
-There were no clear findings regarding the most effective strategies for dissemination and implementation of guidelines. A couple of RCTs testing multifaceted approaches (which incorporated feedback, reminders, prompts, etc) only found modest effects on the adherence to treatment guidelines.
-What is pretty clear is that passive dissemination, such as simply issuing guidelines, do NOT work. To quote a memo that David sent me, “There is now more then sufficient evidence to suggest that implementation of EBP using the “diffusion” model has had and continues to have very limited success. Consider how little impact or successful implementation an appreciable amount of patient safety research evidence or EBP that’s been produced, diffused and disseminated over the past seven years has had. (Leape and Berwick drew this conclusion in a May 2005 JAMA article.) For example, we still cannot seem to reduce or prevent hospital-acquired infections in the US (that kill 99,000 Americans annually) despite sound evidence and “550” interventions noted by the National Implementation Research Network (“Implementation Research”, pg. 72).”
-He also shared an ethnographic study that I thought had lots of relevance for social workers. Gabbay and le May did an ethnographic study entitled, “Evidence based guidelines or collectively construed “mindlines?”: ethnographic study of knowledge management in primary care”. The study examined in depth how health care clinicians (nurses and doctors in tow primary care clinics in England) made decisions. Using observations, case reviews, in-depth interviews, they found that “clinicians rarely accessed and used explicit evidence from research or other sources directly, but relied on “mindlines”—collectively reinforced, internalized, tacit guidelines…Mediated by organizational demands, mindlines were iteratively negotiated with a variety of key actors, often through a range of informal interactions in fluid “communities of practice” resulting in socially constructed “knowledge in practice.” (from British Medical Journal, October 30, 2004, volume 329, pp.1-5)
Anyway, all this to say that developing the guidelines in social work is important— but as I have said before on this site, we need to pay much more attention to the implementation issue and how we can engage social workers in the development and making sense of the guidelines so that the “mindlines” that we all use for our “knowledge in practice” is based on the research and evidence. This will require a much more careful consideration of context, and will require a more complicated set of activities to support and sustain. And, we need to continue to learn from those who have already done research on these issues for some time.
Hope this is useful – sorry to ramble on.
Melissa
I came across a few very interesting reports from the Ministry of Education in New Zealand, “Guidelines for Generating a Best Evidence Synthesis (BES).” In their reports, they describe this method as a different approach from those taken by many traditional or systematic reviews and that it is an iterative process. They also write that the BES requires “cross-paradigm knowledge building work, attention to theoretical pluralism, responsiveness to diversity, and understanding to the needs of multiple audiences.” In another paper about this process, the authors wrote that the BES has a commitment to the “significance of context, critical realism, rigorous eclectism (love that phrase!), use of outcome-linked case studies, attention to evidence about chage processes and to a collaborative approach.” Anyway — I thought the documents were quite illuminating and clearly advocate for mixed methods research and the importance of getting input and ownership from practitioners who will be using the evidence as well as taking a multidisciplinary approach. They acknowledge that this is quite a different approach from the US Dept. of Ed’s Institute of Education Sciences which advocates for RCTs as the gold standard which is also the common position that is promoted, funded and taught in the US. I would be interested to hear other folks thoughts about New Zealand’s approach — seems to be one that is consistent with social work values while still maintaining the need for rigor AND relevance….
See these links for New Zealand’s reports (scroll down the page to BES Conference, Working & OECD Papers):
http://www.educationcounts.edcentre.govt.nz/research/Bes/index.html