Woolf has outlined four general approaches to developing clinical practice guidelines: informal consensus, formal consensus methods, evidence-based approaches, and explicit approaches.² Under the informal consensus process (or “global subjective judgment”), a group of experts make recommendations based on a subjective assessment of the evidence, with little description of the specific evidence or process used.¹ This approach offers the advantages of simplicity and flexibility, as experts familiar with the topic can reach consensus more quickly and can use clinical and research experience to bridge existing gaps in the evidence. Although informal consensus remains the most common method used to develop guidelines, it is difficult for potential users of such guidelines to judge whether the conclusions are valid or appropriate for a specific population. A consensus process may simply reinforce the biases of the assembled experts, and even when not overtly biased, the guidelines may reflect the narrow perspective of specialists rather than the intended audience.The Use Of Evidence-Based Guidelines In Practice By Patient Provider, Healthcare Agency Essay Paper

To guard against some of these problems, more formal consensus methods have been developed, most notably by the Consensus Development Conferences of the National Institutes of Health (NIH), which has produced more than 100 consensus statements over 18 years.^3,4 To reduce the potential for bias, NIH panels include methodologists, clinicians, and public representatives but exclude persons “identified with strong advocacy positions regarding the topic.” Experts representing a range of opinions are invited to present and discuss the evidence at a session open to the public. Other formal approaches to develop expert consensus have been adopted by the American Medical Association Diagnostic and Therapeutic Technology Assessment Program,⁵ the RAND Corporation,⁶ and various health plans.⁷ Because neither formal nor informal consensus methods require that recommendations be explicitly linked to the evidence, it may be difficult to distinguish recommendations based on strong empiric evidence from those based primarily on expert opinion.The Use Of Evidence-Based Guidelines In Practice By Patient Provider, Healthcare Agency Essay Paper

In the 1980s, several national and international organizations pioneered efforts to anchor guidelines more directly to the scientific evidence. The Canadian Task Force on the Periodic Health Examination (CTFPHE),⁸ the U.S. Preventive Services Task Force (USPSTF),⁹ and the Clinical Efficacy Assessment Program of the American College of Physicians (in collaboration with the Blue Cross and Blue Shield Association)^10,11 have each produced a series of guidelines using an evidence-based approach that defines the specific questions to be answered, establishes criteria for including potential evidence, and specifies a systematic process for locating and evaluating relevant evidence. Panels issue recommendations that explicitly reflect the weight of the accumulated evidence. This approach has been credited with improving the reliability and validity of resulting guidelines,¹² and is increasingly being incorporated by other groups. As employed by many groups, however, the evidence-based approach often focuses on a single outcome (e.g., disease-specific mortality) without quantifying other important outcomes.The Use Of Evidence-Based Guidelines In Practice By Patient Provider, Healthcare Agency Essay Paper

Eddy has outlined an explicit approach that builds on the evidence-based approach by systematically estimating the effects of interventions on all important health outcomes.¹He distinguishes between outcome-based approaches, which simply describe the probabilities of various outcomes, and preference-based approaches, which also incorporate patient preferences to determine the best clinical strategy for groups or individuals. Outcomes-based or preference-based methods have been incorporated to varying degrees in a number of guidelines, including some developed by the Agency for Health Care Policy and Research (AHCPR),^13,14 the American College of Physicians (ACP),¹⁵ and the Office of Technology Assessment The Use Of Evidence-Based Guidelines In Practice By Patient Provider, Healthcare Agency Essay Paper

In the process of developing evidence-based or outcome-based guidelines, reviewed in a number of recent publications, each step is specified, from selecting topics to crafting precise wording of the guideline.^12,18–20

A recent Institute of Medicine report recommended six general criteria to select appropriate topics for guidelines: prevalence of the condition; burden of illness (i.e., morbidity and mortality); costs of treatment; variability in practice; potential for a guideline to improve health outcomes; and potential for a guideline to reduce costs.¹⁸Although most organizations loosely follow these recommendations, few have formal processes for selecting topics. Professional societies need also to consider specific needs of their membership, while government agencies may have other political considerations.The Use Of Evidence-Based Guidelines In Practice By Patient Provider, Healthcare Agency Essay Paper

It is equally important to specify the target audience and clinical setting for which a guideline is intended. This in turn defines the scope of the guideline, the evidence to be considered, and the composition of the panel. Unless the clinical setting and intended audience are specifically considered, the resulting guideline may be impossible to implement effectively. Many guidelines produced by the Centers for Disease Control and Prevention (CDC), American Cancer Society (ACS), and NIH that deal with primary care issues have paid little attention to critical factors that will determine whether a guideline will be accepted and implemented: cost implications, time or technology required, competing demands of more common problems, and patient preferences.

Although explicit, evidence-based methods improve the consistency and reliability of resulting guidelines, the composition of the guideline panel can still profoundly influence the process and resulting product. The size and composition of the panel must balance scientific, practical, and political concerns. Guideline panels generally range from 10 to 20 members; within this range, smaller sizes facilitate decision making and decrease costs, but allow less diverse representation. The distribution between specialist-experts and generalists is another important consideration.¹² Recognized experts bring an important perspective to the scientific review process and are an important source of credibility for the resulting guideline. At the same time, experts are more likely to be influenced by their personal involvement with specific treatments or research.¹⁹ Panels can balance this tendency by including individuals with expertise in research methodology, generalist physicians, nonphysician health professionals, and patient or consumer representatives. Multidisciplinary representation, however, makes it harder for all panelists to participate equally in all steps of the process and may complicate reaching consensus. Nonphysician panelists have been routinely and effectively included in AHCPR panels, but the recent USPSTF, CTFPHE, and ACP panels emphasized the role of generalist physicians with methodologic expertise. These panels use extensive peer review of draft guidelines to obtain both expert and multidisciplinary input.The Use Of Evidence-Based Guidelines In Practice By Patient Provider, Healthcare Agency Essay Paper

The primary obstacle to evidence-based guidelines remains the paucity of well-designed research for many of the treatments and technologies in common use. This is a particular problem in assessing the clinical benefits of many screening and diagnostic tests. When direct evidence is not available to link an intervention to an improved health outcome (e.g., cholesterol screening to reduced coronary heart disease), indirect evidence of effectiveness may be provided by studies of intermediate steps in the causal process (e.g., the accuracy of screening tests for identifying patients with high cholesterol, and the effectiveness of cholesterol-lowering treatments in such patients for reducing coronary events).The Use Of Evidence-Based Guidelines In Practice By Patient Provider, Healthcare Agency Essay Paper

Battista and Fletcher first outlined a concept of “causal pathways” as an explicit method to describe the use of indirect evidence to establish effectiveness (Figure 1).²¹ An important function of this process is that it identifies both specific beneficial health outcomes and potential adverse consequences at each step of a sequence of interventions. Subjective judgments may still be involved in deciding whether indirect evidence is sufficient (e.g., whether effectiveness of cholesterol-lowering drugs can be inferred for women), but explicitly describing the evidence for each step and outcome allows guideline users to understand and judge the reasoning behind the recommendations.

A systematic review of the literature must be conducted to retrieve relevant evidence for each question identified. Panels may differ in the eligibility criteria they set: some may include any study in which methods can be independently assessed, whereas others may limit themselves to peer-reviewed, published studies. The work of the Cochrane Collaboration may make it easier for panels to include unpublished studies, but these efforts are currently confined to controlled trials. Computerized searches of bibliographic databases such as MEDLINE should be supplemented by reviewing bibliographies of key articles, contacting key experts, and consulting the work of international groups conducting systematic reviews.^22,23 Government documents and reports that archive important disease-specific information will also be missed in MEDLINE, requiring reviewers to contact government agencies involved in research or program administration for some conditions.The Use Of Evidence-Based Guidelines In Practice By Patient Provider, Healthcare Agency Essay Paper

A critical and often contentious step of the evidence-based process is evaluating the quality of individual studies, including assessment of the internal and external validity of study results. Internal validity is a function of both study design and its implementation. Although certain study designs, (such as randomized controlled trials [RCT ’s]), are less prone to bias, many factors may compromise the internal validity of an individual trial: inadequate power, improper design or analysis, incomplete follow-up, inappropriate end points, or ineffective implementation of the intervention. Confounding, selection bias, and measurement error are important considerations for observational studies. Standardized methods for assessing individual studies have been described.^1,22,24Equally important is whether the results of an individual study are relevant to the general population (i.e., external validity). Unrepresentative study populations or clinical settings and impractical interventions may compromise the external validity of an otherwise well-conducted clinical trial. Even when a study provides good evidence of efficacy (i.e., results under ideal conditions), guideline developers need to consider that the effectiveness of an intervention (i.e., results under typical conditions) may be substantially lower when implemented in the real world.The Use Of Evidence-Based Guidelines In Practice By Patient Provider, Healthcare Agency Essay Paper

Panels will often need to turn to expert opinion to address important questions for which definitive evidence is not available. Both informal methods and formal methods (e.g., the Delphi technique) can be used, but care should be taken to solicit a broad range of opinion and to clearly distinguish recommendations supported by the evidence from those based primarily on opinion.

Summary estimates of the effects of alternative treatment strategies can be represented as a balance sheet depicting discrete benefits (e.g., reduced mortality and morbidity, improved quality of life) and harms (fatal and nonfatal complications or side effects) for each strategy. When patient preferences can be estimated for specific outcomes, outcomes can be converted into a common denominator such as quality-adjusted life years to calculate the net effect (benefits minus harms) of a certain strategy. When treatments have clear effects on mortality with limited adverse effects (e.g., angiotensin-converting enzyme inhibitors for congestive heart failure), detailed balance sheets may not be necessary. However, when interventions primarily improve symptoms but involve important risks (e.g., surgery for benign prostatic hyperplasia), such balance sheets can help illustrate the tradeoffs involved. Cost-effectiveness, as a cost per life year or quality- adjusted life year, can be modeled. Unfortunately, the complexity of such models and the numerous assumptions that must be made to estimate parameters for them, may make their conclusions less credible to the average clinician, especially when results contradict prevailing practice.The Use Of Evidence-Based Guidelines In Practice By Patient Provider, Healthcare Agency Essay Paper

The hallmark of the explicit, evidence-based approach is that each recommendation directly reflects the strength of underlying evidence. Different groups have used different hierarchies to depict this link. The USPSTF and CTFPHE use separate hierarchies to describe both the level of the evidence (I–III) and the strength of the overall recommendation (A–E), whereas AHCPR panels have used simpler A-B-C categories to distinguish recommendations based on definitive trial evidence, those based on weaker evidence, and those based on expert opinion.

Guideline panels inevitably struggle to balance their desire to create guidelines that are forthright and unambiguous, with the recognition that no guideline can supplant the role of clinical judgment about the individual patient. Often, guidelines seek to convey these distinctions with subtle language distinctions (“X may be useful”). As guidelines are increasingly being used to measure quality or guide reimbursement, they will need to distinguish those measures for which there is clear and compelling evidence of important benefits (e.g., childhood vaccinations), measures that should be encouraged but not required (e.g., sigmoidoscopy), and interventions for which the best strategy depends largely on clinician judgment and patient preference (e.g., hormone replacement therapy). The American Academy of Family Physicians has proposed such an approach in adapting the recommendations of the USPSTF, classifying services as “standards,” “guidelines,” or “options.”The Use Of Evidence-Based Guidelines In Practice By Patient Provider, Healthcare Agency Essay Paper

The final component necessary to ensure the reliability of clinical guidelines is peer review from a range of outside reviewers, including content experts, representatives of professional societies, government organizations and consumer groups, and potential guideline users. It is now important that the latter group include representatives of managed care and insurers along with practicing clinicians, as these groups may be critical components of guideline implementation. Although it is useful and important to solicit comments from a wide range of reviewers, it is also important to recognize that the perspective and motivation of many reviewers may differ from those of the intended audience. For example, subspecialists are important for addressing scientific issues but most likely to have different priorities than primary care clinicians.The Use Of Evidence-Based Guidelines In Practice By Patient Provider, Healthcare Agency Essay Paper

Recent guidelines on prostate cancer screening issued by the ACP¹⁵ and by the USPSTF⁹ illustrate two approaches to explicit, evidence-based guidelines and the strengths and weaknesses of each approach. Figure 1 depicts a causal pathway describing the steps linking screening with prostate-specific antigen (PSA) to improved health outcomes. At present, there is no direct evidence that men screened for prostate cancer have lower mortality or morbidity from prostate cancer compared with unscreened men (step 1); a large, multicenter randomized trial of PSA screening is under way to address this issue. To establish support for screening in the absence of such evidence, one must demonstrate that screening can improve early detection of prostate cancer (step 2), that treatment of asymptomatic prostate cancer is more effective than treatment of clinically apparent cancer (step 3), and that these benefits justify the potential adverse effects of screening (step 4) and treatment (step 5). Most proponents of screening base their argument on the growing evidence for step 2 with an assumption that early treatment can improve outcomes, based primarily on prostatectomy series demonstrating favorable outcomes for patients with localized prostate cancer compared with those who have advanced disease.The Use Of Evidence-Based Guidelines In Practice By Patient Provider, Healthcare Agency Essay Paper

Evidence-based groups have recognized numerous problems in using such uncontrolled data to infer a benefit of early detection: lead-time bias, length bias, and selection bias all could result in apparent survival benefit even if treatments were ineffective; mortality results ignore important consequences of treatment on quality-of-life; and experience with cancers detected in the pre-PSA era may not apply to the small, indolent cancers now being detected with widespread screening. The lack of evidence that early detection was beneficial, and concern that risks of screening and aggressive therapies could actually exceed benefits, led the USPSTF⁹ and CTFPHE⁸ to discourage routine screening in asymptomatic men. Such a recommendation reflected the underlying philosophy of these groups that, when proposing interventions to asymptomatic persons, clinicians should be guided by a principle of “first do no harm.”The Use Of Evidence-Based Guidelines In Practice By Patient Provider, Healthcare Agency Essay Paper

These recommendations can frustrate clinicians who are concerned about the toll of prostate cancer and see a plausible (if not yet proven) potential for early detection to reduce cancer deaths. The assessment of prostate cancer screening done by the Office of Technology Assessment¹⁹ and the recently released guideline developed by the ACP from a similar analysis¹⁵ used an outcome-based model to explore the range of possible benefits and risks of screening in different populations. The models used available evidence to estimate the accuracy of PSA, prevalence and prognosis of cancers of various grades, and the costs and complications of screening and prostatectomy (see Table 1); because data on treatment efficacy are lacking, they used assumptions favorable to screening (100% effectiveness for organ-confined cancers) and sensitivity analysis to examine how screening decisions might differ if treatments were less effective. As depicted in Table 1, even if treatments are 100% effective, the benefits of screening men over 70 years of age (cancer deaths prevented) are offset by the large number of men who suffer excess morbidity from treatment. Under the same assumptions, screening younger men (aged 50–70 years) offered a more favorable balance of risks and benefits (although the absolute benefit remains small) and could be reasonably cost-effective.¹⁵ Screening men over 70 is cost-ineffective under the most optimistic of assumptions (>$65,000 per life year saved) and could result in a net decrease in quality of life if treatments are less than optimally effective or if lower disease-progression rates are assumed.^15,19 Although these analyses require a number of assumptions, they make clear that the value of screening depends critically on how effective therapies are and on how likely untreated cancers are to progress in a patient's lifetime. Although consistent with the fundamental uncertainty of the evidence, the ACP guideline¹⁵ provides room for clinicians and patients to reach their own decision about dealing with an intervention of possible but unproven benefit: it recommends against screening average-risk men before age 50 or after age 70, but leaves screening optional for men aged 50 to 70 years. If screening is offered, however, it should be accompanied by a careful explanation of its potential benefits and risks and the underlying uncertainties about effectiveness.The Use Of Evidence-Based Guidelines In Practice By Patient Provider, Healthcare Agency Essay Paper

Clinical practice guidelines have always been at the heart of medical practice. The current national dialogue on guidelines is driven not so much by the question of whether there should be guidelines, but by how to see that they are followed. This emphasis on effective implementation is due to the unacceptably high cost of health care and has the two goals of avoiding paying for unnecessary (or unnecessarily high-cost) health care, and making sure that, when costs are cut, the quality of health care does not suffer.

Implementing guidelines can be cost-saving, especially for those that are specifically written to deal with the costly aspects of health care (e.g., “negative drug detailing” aimed at reducing the use of unnecessarily costly drugs). However, balanced practice guidelines should deal with errors of omission as well as commission. Correcting errors of omission (e.g., not providing indicated preventive care, or not treating patients with left ventricular dysfunction with a converting enzyme inhibitor) may, at least in the short run, be more costly. In such cases, the practitioners must define as high-quality care actions that are cost-effective, if not cost-saving. They can then use guidelines to encourage (or enforce) such care. Providing the best care, even if the clinical benefits are in the future, is the “good” extracted at the “cost” of using practice guidelines. Finally, one must not exclude from calculations of the cost-effectiveness of guidelines the costs of developing guidelines (costs = personnel time) and implementing them (costs = data extraction + data management + provision of interventions of feedback to providers).The Use Of Evidence-Based Guidelines In Practice By Patient Provider, Healthcare Agency Essay Paper

The aspects of health care likely to reap the most benefit from the application of practice guidelines are those for which there is demonstrable variation in care provided, costs, or outcomes. One might begin with the most serious and costly conditions for which compliance with well-constructed guideline protocols is suboptimal. For example, guideline efforts would be better focused on thrombolytic care for acute myocardial infarctions in the emergency department or influenza vaccination of elderly outpatients than on screening for hypercholesterolemia among asymptomatic elders.

The first controlled trials of guideline implementation were reminder studies in which the most common and effective reminders were triggered by simple demographic data (age and gender) and compliance was monitored by noting whether an appropriate order was written, a test result was obtained, or a drug was prescribed.^25–28 Even simple guidelines may prove difficult and time-consuming to design and implement at first; but with experience and improved data systems, more complex guidelines will be easier to accomplish. The most sophisticated guideline systems currently are those in which orders for specific testing and therapy are suggested via algorithms built into physicians’ order-writing workstations.²⁹ Early studies show that, when physicians intend to comply with such suggestions, compliance is enhanced.³⁰ When they believe the suggestions are inappropriate, they do not comply (which is reassuring) The Use Of Evidence-Based Guidelines In Practice By Patient Provider, Healthcare Agency Essay Paper

Physicians and other health care providers are not accustomed to having their care audited. A common response to the promulgation and enforcement of guidelines is that they will lead to “cookbook medicine.” Of course, blindly following general rules will obscure valid individual differences and result in poor care. Guidelines should only apply to between 60% and 95% of relevant cases.³² Yet physicians often further simplify decision-making processes by invoking rules of thumb termed heuristics.³³ Such rules (a form of guideline) are one way of dealing with information overload by simplifying complex rules and information matrices into a smaller number of overriding “truths.” Occam's razor is a familiar heuristic: choose the simplest hypothesis that explains the most findings.³⁴

Two keys are necessary in order to apply guidelines in clinical practice. First, the providers within a practice must believe that the guidelines are appropriate and intend to follow them. Second, the practice must have access to sufficient data and sufficiently specified rules.The Use Of Evidence-Based Guidelines In Practice By Patient Provider, Healthcare Agency Essay Paper

Intention to comply with guidelines is the strongest predictor of compliance.²⁵Conversely, when physicians do not intend to comply with guidelines, they will not comply despite being reminded to do so on a case-by-case basis.³¹

Physician confidence in the correctness of a guideline depends on the methods used to construct the guideline and who does the work. Examples of evidence-based guidelines are those from the USPSTF,⁹ the CTFPHE,⁸ and the AHCPR. Guidelines can also be established by the consensus of medical experts. Examples include guidelines for the treatment of heart disease from the American College of Cardiology³⁵ and the long series of consensus conferences held by the NIH.⁴ Internists have more faith in specialty societies than in government or regulatory agencies.³⁶ This is likely due to the belief that physicians are motivated to provide the highest-quality care, while the motives of other organizations may be suspect. Internists fear that the goal of guidelines promulgated from nonprofessional organizations is mainly to reduce the cost of care The Use Of Evidence-Based Guidelines In Practice By Patient Provider, Healthcare Agency Essay Paper

Evidence‐based practice (EBP) is a problem‐solving approach to the delivery of health care that integrates the best evidence from well‐designed studies and evidence‐based theories with a clinician's expertise and a patient's preferences and values in making the best clinical decisions (Melnyk & Fineout‐Overholt, 2014). Clinical practice guidelines, which should be routinely incorporated into EBP, are statements with recommendations for clinical practice that are rigorously developed based on systematic reviews of evidence and an evaluation of their benefits and harms (Melnyk et al., 2012). Guidelines are important tools in EBP that can reduce healthcare variation and improve patient outcomes. However, guidelines produced from multiple sources often conflict with one another, which can be confusing for clinicians. Further, many clinicians unknowingly follow recommendations and guidelines that have not undergone rigorous development. For example, Belamarich, Gandica, Stein, and Racine (2006) conducted a study in which findings revealed that none of the 162 verbal health advice directives from 57 policy statements by the American Academy of Pediatrics on which pediatricians should provide council to their patients and parents included the evidence upon which the advice should be based. In another review of 53 guidelines by the American College of Cardiology and the American Heart Association, it was found that the recommendations were largely based on lower level evidence such as nonrandomized trials, case studies, and expert opinions (Tricoci, Allen, Kramer, Califf, & Smith, 2009). Since many clinicians turn to their professional organizations to provide guidelines that can be incorporated into care, it is critical for them to understand not only how guidelines should be formulated, but also how to critically appraise them and where the best “gold standard” guidelines can be accessed.The Use Of Evidence-Based Guidelines In Practice By Patient Provider, Healthcare Agency Essay Paper

The Institute of Medicine (IOM) in the United States has described eight attributes of good guideline development (IOM, 2011). These attributes include: (a) validity, (b) reliability and reproducibility, (c) clinical applicability, (d) clinical flexibility, (e) clarity, (f) documentation, (g) development by a multidisciplinary process, and (h) plans for review.

Two groups that undergo rigorous processes to develop evidence‐based recommendations and guidelines are the United States Preventive Services Task Force (USPSTF) and the Registered Nurses Association of Ontario, Canada (RNAO). The USPSTF is comprised of a group of 16 scientists and experts in primary care who produce evidence‐based recommendations for clinical preventive services, such as screening tests (e.g., mammography; lipid screening), behavioral counseling services, and preventive medications. More than 100 recommendations are published in an annual updated guide for clinicians entitled Guide to Clinical Preventive Services, which can be accessed  The Use Of Evidence-Based Guidelines In Practice By Patient Provider, Healthcare Agency Essay Paper at http://www.ahrq.gov/professionals/clinicians‐providers/guidelines‐recommendations/guide/index.html. The USPSTF receives support for its work from the Agency for Healthcare Research and Quality's (AHRQ) funded EBP centers, which conduct systematic reviews of evidence for the task force. The reviews that are conducted by the EBP centers are guided by a set of key questions and an analytic framework that includes the benefits and harms of the recommendations for each topic selected by the task force (Melnyk et al., 2012). Each systematic review conducted by an EBP center is brought to the task force for review and critical appraisal. Before an evidence‐based recommendation is released in final form by the USPSTF, feedback from national experts and the public is sought. Recommendations from the USPSTF receive a recommendation of either: A (the USPSTF recommends the service; there is high certainty that the net benefit is substantial); B (the USPSTF recommends the service; there is high certainty that the net benefit is moderate); C (the USPSTF recommends against routinely providing the service; there is at least moderate certainty that the net benefit is small); D (the USPSTF recommends against the service; there is moderate to high certainty that the service has no net benefit or that the harms outweigh the benefits); or I (the USPSTF concludes the current evidence is insufficient to assess the balance of benefits and harms of the service; see http://www.ahrq.gov/CLINIC/upstix.htm).The Use Of Evidence-Based Guidelines In Practice By Patient Provider, Healthcare Agency Essay Paper

The RNAO also has rigorously produced and disseminated over 50 best practice guidelines that focus on clinical topics (e.g., assessment and management of pain, assessment and management of stage I to IV pressure ulcers, breastfeeding best practices) and healthy work environments (e.g., preventing and mitigating nurse fatigue; preventing and managing violence in the workplace). These guidelines are available and freely downloadable on its website at http://www.rnao.org, and are widely used throughout Canada as well as internationally. There also is a toolkit and educator's resource available to assist with guideline implementation.The Use Of Evidence-Based Guidelines In Practice By Patient Provider, Healthcare Agency Essay Paper

Another excellent source for clinical practice guidelines (CPGs) is the National Guideline Clearinghouse (NGC), which is an initiative of AHRQ. The NCG, originally developed as a partnership between the American Medical Association and the American Association of Health Plans, is a comprehensive database of over 10,000 clinical guidelines from developers throughout the world (see http://guideline.gov). To be considered for inclusion in the NGC, guideline developers must conduct a systematic literature search and review of existing evidence published in peer‐reviewed journals. All guidelines housed at the NGC must be developed, reviewed, or revised in the last 5 years. Expert commentaries that provide insights on current issues of importance to CPGs also are available. In addition, a nice feature of the NGC allows clinicians to register to receive weekly e‐mails that outline changes in the practice guidelines housed on this site.The Use Of Evidence-Based Guidelines In Practice By Patient Provider, Healthcare Agency Essay Paper

Once a CPG is accessed, critical appraisal of the guideline should be performed. Strength of clinical practice guidelines is based on their validity and reliability of the recommendations (Grinspun, Melnyk, & Fineout‐Overholt, 2014). Some key rapid critical appraisal questions to ask when reviewing a CPG include:

• Who were the guideline developers?
• Did the team have a valid development strategy?
• Was an explicit, sensible and impartial process used to identify, select, and combine evidence?
• Did the developers carry out a comprehensive, reproducible literature review within the past 12 months of its publication or revision?
• Were all important options and outcomes considered?
• Is each recommendation in the guideline tagged by the level or strength of evidence upon which it is based and linked with the scientific evidence?
• Has the guideline been subjected to peer review and testing?
• Are the recommendations clinically relevant?
• Will the recommendations help me in caring for my patients (Melnyk & Fineout‐Overholt, 2014)?The Use Of Evidence-Based Guidelines In Practice By Patient Provider, Healthcare Agency Essay Paper

It must be remembered that access to and dissemination of CPGs alone often does not result in their wide‐scale uptake in real world practice settings. Implementing CPGs in healthcare systems often requires a multipronged approach that includes targeted intervention strategies with both clinicians and the healthcare system (Grinspun, Melnyk, & Fineout‐Overholt, 2014). The culture and environment of the system in which the CPGs are to be implemented must be carefully assessed in order to identify strengths and barriers to adoption of the new guideline, followed by the development of a strategic plan to overcome barriers in widespread implementation. Top leadership and middle management support, provision of EBP mentors, grassroots efforts by clinicians, along with tools and resources that support implementation are all necessary for successful wide‐scale adoption and sustainability (Melnyk, 2007, 2014). The Use Of Evidence-Based Guidelines In Practice By Patient Provider, Healthcare Agency Essay Paper