1. Clinical Practice Guidelines Research & Education Perspectives Susan Rappolt Department of Occupational Therapy University of Toronto s.rappolt@utoronto.ca

2. 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

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

4. 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

5. 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)

6. 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

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

8. Re-thinking Professional Expertise in Client-Centred Evidence-Based Practice Stage 2 Research Evidence Stage 4 Decision-Making Stage 1 Client Evidence Stage 3 Integration of Evidence Stage 5 Enablement and Evaluation 1. Discuss evidence with client 1. Identify problem and research question 1. Establish applicability and appropriateness 1. Gather and appraise client evidence 1. Further assessments as needed 2. Undertake processes for enablement 2. Gather relevant evidence 2. Develop collaborative plans for intervention 2. Identify occupational performance issues 2. Determine method 3. Evaluate outcomes 3. Appraise quality of evidence 3. Identify evaluation criteria 4. Anticipate outcomes Professional Role The Role of Professional Expertise in CCEP Collaborative Role Collaborative Role Collaborative Role Clinical Expertise Professional & Client Professional & Client Professional & Client C L I E N T O U T C O M E Professional Role Research Expertise SPECIFIC CONTEXT OF PRACTICE

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

10. Functions of CPGs • For the Client: • Transparent treatment plans for informed collaborative decision-making • Fosters best possible clinical practice • Promotes best possible clinical outcomes

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. How to Evaluate a CPG: • Defined scope and purpose • Stakeholder involvement • Rigorous development • Clear and well presented • Applicability • Editorial independence

18. 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

19. Experiences of Other Professions with CPGs • Physiotherapy • Nursing • Medicine

20. 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

21. Clinical Practice Guidelines? • What are the alternatives?