Evidence-Based Practice: A Guide to Negotiate the Clinical Practice Guideline Maze

Article excerpt

The charge for this issue's column was to write about evidence-based practice and dementia, the issue's theme. This was quite a challenge because, as first author, I did not have expertise in the health problems of dementia and so had no idea about the evidence that may be out there. Being somewhat resourceful, I decided to ask MaryJo Vetter, a geriatric nurse practitioner with whom I have been working at the Visiting Nurse Service of New York, to coauthor this column with me. We first talked about what approach to take in writing as there is an abundance of published information on the topic and this column is certainly not a vehicle for a state-of-the art paper. Several professional activities in which Levin has been engaged over the past year helped focus and narrow our approach.

During the past year, Levin consulted with the Hartford Institute for Geriatric Nursing at New York University to provide a framework for revising teaching materials using an evidence-based approach. Prior to that, working with a faculty colleague at Pace University, she devised a teaching strategy to use with family nurse practitioner students to develop their ability to critically appraise clinical practice guidelines (Singleton & Levin, 2006). In both of these endeavors, the AGREE instrument (AGREE Collaboration, 2001) was used.

According to Lucas and Fulmer (2003), "Clearly, best practice protocols and guidelines are not valuable for clinical decision making unless they are up-to-date and provide current evidence from research" (p. 2). Lucas and Fulmer also point out that the knowledge base for geriatric nursing is growing rapidly. Therefore, the ability to assess clinical practice guidelines for their validity and incorporation of the best available evidence are crucial.

Also important is to define what we mean by clinical practice guidelines. So let us first define relevant terms. Guidelines, protocols, and recommendations are often used interchangeably by health professionals. A recommendation is a suggestion for practice, not necessarily sanctioned by a formal, expert group. A clinical practice guideline (CPG) is an official recommendation or generally prescribed approach to diagnose and manage a broad health condition, such as heart failure, smoking cessation, pain management, or dementia. A protocol is a more detailed guide for approaching a clinical problem or patient health condition and is tailored to a specific practice situation. The validity of any of these practice guides can vary depending on the type of evidence upon which they are based and other factors, such as the composition of the group charged with their development (Rich & Newland, 2006). How does one begin to tackle this challenging task?

In 2001, the AGREE instrument for the appraisal of guidelines was released in its final form. The process that led to its development began, however, in 1992 with the development of an appraisal instrument for the National Health Services, supported by the United Kingdom National Health Services Management Executive. Funding for the AGREE instrument, an international effort, was later provided by the European Union (AGREE Collaboration, 2001). The instrument contains 23 items categorized into six quality domains: scope and purpose, stakeholder involvement, rigor of development, clarity and presentation, application, and editorial independence. For example, when evaluating scope and purpose, evaluators respond to three items (Figure 1). To increase the reliability of the instrument there must be more than one appraiser for each guideline. A 4-point Likert scale, from strongly disagree to strongly agree, is scored for each item within a domain. Individual domain scores are the outcome, which, based on a review of domain scores, allow the appraiser to give a subjective assessment of the guideline. We can come to a subjective conclusion related to the overall assessment, but the instrument does not recommend averaging domain scores for a total quantitative rating. …