The need for locally appropriate guidelines
Clinical practice guidelines transform knowledge into action during health care delivery and clinical practice. Good clinical guidelines can change healthcare delivery, improve patient outcomes and quality of care, and help make efficient use of healthcare resources. High quality guidelines must be built upon unbiased and transparent processes of systematic review, appraisal and use of the best clinical research findings.
A core function of WHO is the development of global guidelines to contribute to improved health policy and care. The WHO Guidelines Review Committee, established in 2007, aims at developing and implementing procedures to ensure that WHO guidelines are: consistent with internationally accepted best practices, appropriately based on evidence and transparent.
One of the challenges to the uptake of WHO guidelines is the variety of contexts and cultures across regions and Member States. Guidelines cannot therefore be necessarily adopted “as is” across settings, which highlights the possible need to adapt these guidelines at the regional, and even at country, level in order to facilitate their uptake.
In that regard, the WHO Regional Office for the Eastern Mediterranean held an expert consultation on evidence-based guideline development and adaptation in the Eastern Mediterranean Region in Cairo, Egypt on 18–19 November 2015. The meeting was held to discuss developing a common approach that the Regional Office could use for the adoption or adaptation of globally developed guidelines (or guidelines developed in other regions/institutions). The meeting brought together a group of regional and international experts in order to: i) review and discuss global/regional experiences in adoption and adaptation of evidence-based guidelines including challenges and actual use of the guidelines in practice and ii) agree the main approaches for a framework of action for the Regional Office to promote the adaptation of globally developed evidence-based guidelines and the development of guidelines in areas of need, and support their implementation in practice.
Participants included experts in clinical practice and public health guideline development and adaptation from Egypt, France, Lebanon, Norway and Saudi Arabia, and WHO staff from headquarters and the Regional Office.
Challenges to guideline development
Several challenges to producing high quality clinical practice guidelines were identified including: the need to reduce unnecessary variation of health care or services; improving processes, and patient and public health outcomes; controlling cost; providing concise summaries of current best evidence and focusing research on areas with inadequate data; lack of adequate or appropriate guidance for development of guidelines; concerns about the quality of existing guidelines (methodological limitations); absence of certain tasks in most handbooks (e.g. ethical issues); feasibility and practicality of piloting of new guidelines; absence of cost-effectiveness considerations in many development programmes.
At the same time challenges to producing high quality global public health guidelines were identified which included: paucity of evidence, especially policy and health system interventions in low–middle income countries; low quality evidence and weak study designs; resource constraints; variety of guideline topics; diverse user needs: applicability and implementation; creating guidelines based on setting-specific evidence; identifying and building capacity for methodological expertise.
Issues in guideline adaptation
The steps for adapting and updating existing clinical practice guidelines include: selecting a priority topic; appraising research; determining the scope; synthesis and analysis; preparing the work plan; reaching consensus; identifying, appraising (including considering ethical issues) and adapting existing clinical practice guidelines; creating recommendations; involving stake-holders; selecting publishing formats; observing conflicts of interests; formulating an implementation strategy; piloting; undertaking impact assessment; developing clinical audit criteria; making economic evaluation; updating and correcting guidelines.
Several adaptation frameworks exist including: Royal College of Nursing (RCN), ADAPTE, Alberta Ambassador Program, Making GRADE the Irresistible Choice (MAGIC), Adolopment, RAPADAPTE frameworks (the latter two are unpublished). Most approaches are built upon ADAPTE, with attempts to improve on specifics aspects, e.g. MAGIC uses a systematic, transparent and reproducible process based on GRADE; Adolopment is based on GRADE and its Evidence to Decision (EtD) framework; RAPADAPTE uses synthesized evidence databases to speed up the process. Evidence to Decision (EtD) frameworks for guideline adaptation also exist, e.g. GRADE/DECIDE Evidence to Decision frameworks.
The Guidelines International Network (GIN) Adaptation Working Group was established in August 2010 with the aims of: supporting methods for efficient guideline development through adaptation of guidelines and evidence sources; refining the adaptation resource toolkit and developing additional adaptation resources; and providing support and training to groups undertaking or planning to undertake guideline adaptation projects.
Available resources to enhance guideline implementation in the field include general resources (books, journals and websites), resources designed to improve health care issues (stakeholder involvement, priority-setting, clinical practice guidelines, measuring performance) and intervention resources (identifying determinants of practice, designing interventions, evaluating interventions, quality improvement programmes).
Several countries in the Region have experience in capacity-building and adaptation of clinical practice guidelines including the Islamic Republic of Iran, Saudi Arabia and Tunisia.
The way forward
Actions directed at academic institution, health care delivery institutions and the WHO Regional Office were recommended to help advance guideline development/adaptation and implementation in the Region (Box 1).
