scholarly journals Early Mobilization After Stroke: Do Clinical Practice Guidelines Support Clinicians' Decision-Making?

2021 ◽  
Vol 12 ◽  
Author(s):  
Venesha Rethnam ◽  
Kathryn S. Hayward ◽  
Julie Bernhardt ◽  
Leonid Churilov

Importance: Early mobilization, out-of-bed activity, is a component of acute stroke unit care; however, stroke patient heterogeneity requires complex decision-making. Clinically credible and applicable CPGs are needed to support and optimize the delivery of care. In this study, we are specifically exploring the role of clinical practice guidelines to support individual patient-level decision-making by stroke clinicians about early mobilization post-stroke.Methods: Our study uses a novel, two-pronged approach. (1) A review of CPGs containing recommendations for early mobilization practices published after 2015 was appraised using purposely selected items from the Appraisal of Guidelines Research and Evaluation–Recommendations Excellence (AGREE-REX) tool relevant to decision-making for clinicians. (2) A cross-sectional study involving semi-structured interviews with Australian expert stroke clinicians representing content experts and CPG target users. Every CPG was independently assessed against the AGREE-REX standard by two reviewers. Expert stroke clinicians, invited via email, were recruited between June 2019 to March 2020.The main outcomes from the review was the proportion of criteria addressed for each AGREE-REX item by individual and all CPG(s). The main cross-sectional outcomes were the distributions of stroke clinicians' responses about the utility of CPGs, specific areas of uncertainty in early mobilization decision-making, and suggested parameters for inclusion in future early mobilization CPGs.Results: In 18 identified CPGs, many did not adequately address the “Evidence” and “Applicability to Patients” AGREE-REX items. Out of 30 expert stroke clinicians (11 physicians [37%], 11 physiotherapists [37%], 8 nurses [26%]; median [IQR] years of experience, 14 [10–25]), 47% found current CPGs “too broad or vague,” while 40% rely on individual clinical judgement and interpretation of the evidence to select an evidence-based choice of action. The areas of uncertainty in decision-making revealed four key suggestions: (1) more granular descriptions of patient and stroke characteristics for appropriate tailoring of decisions, (2) clear statements about when clinical flexibility is appropriate, (3) detailed description of the intervention dose, and (4) physical assessment criteria including safety parameters.Conclusions: The lack of specificity, clinical applicability, and adaptability of current CPGs to effectively respond to the heterogeneous clinical stroke context has provided a clear direction for improvement.

2020 ◽  
Author(s):  
Ivan D Florez ◽  
Melissa C Brouwers ◽  
Kate Kerkvliet ◽  
Karen Spithoff ◽  
Pablo Alonso-Coello ◽  
...  

Abstract Background: A new tool, the AGREE-REX, was recently developed to support the development, reporting, and assessment of clinical practice guidelines’ (CPGs) recommendations, and to complement the AGREE II tool. We assessed the credibility and implementability of 161 CPGs recommendations using the AGREE-REX draft tool. Methods: Cross sectional study. CPGs were assessed by two independent appraisers using the AGREE-REX draft tool. The CPGs were rated with the tool’s 7-point response scale for each item. Differences between CPGs according to country, year and type of organization (government-supported/professional society) were evaluated. One-way ANOVA tests were used to examine differences in the score. Results: Recommendations from 161 CPGs from 70 organizations were appraised by 322 participants from 51 countries, using the AGREE-REX draft tool. The total overall average score of the recommendations was 4.23 (standard deviation(SD)=1.14). AGREE-REX items that scored the highest were (mean; SD): Evidence (5.51; SD=1.14), Clinical relevance (5.95; SD=0.8), and Patients/population relevance (4.87; SD=1.33), while the lowest scores were observed for the Policy values (3.44; SD=1.53), Local applicability (3,56; SD=1.47) and Resources, tools and capacity (3.49; SD=1.44) items. CPGs developed by government-supported organizations and developed in the UK and Canada had significantly higher recommendation quality scores with the AGREE-REX tool (p=0.01) than their comparators.Conclusions: We found that there is significant room for improvement of some CPGs such as the considerations of patient/population values, policy values, local applicability and resources, tools and capacity. These findings may be considered a baseline upon which to measure future improvements in the quality of CPGs.Contribution to the literature· We applied the AGREE II and the recently developed tool (AGREE-REX draft version), to assess quality, credibility and implementability of 161 international clinical practice guidelines (CPGs). The AGREE REX draft tool was applied by 322 guidelines’ developers, users and researchers from 51 countries.· The scores of the AGREE REX draft tool items were higher in those items related to the quality of the evidence and the clinical relevance. The items related to patients and population relevance and implementation relevance scored in the mid-range, while the items related to patients/population or policy values, the alignment of values, the local applicability, and the resouces, tools and capacity items scored low.· CPGs produced by government-supported organizations scored higher on all the items of the AGREE-REX draft tool than those produced by professional societies or other types of groups, and CPGs produced in United Kingdom and Canada scored higher in selected items in comparison to United States and international CPGs· The correlations between the overall AGREE-REX draft tool and AGREE II domains were low, except for the Applicability domain where the correlation was modest.


2020 ◽  
Vol 15 (1) ◽  
Author(s):  
Ivan D. Florez ◽  
Melissa C. Brouwers ◽  
Kate Kerkvliet ◽  
Karen Spithoff ◽  
Pablo Alonso-Coello ◽  
...  

Abstract Objective To assess the quality of recommendations from 161 clinical practice guidelines (CPGs) using AGREE-REX-D (Appraisal of Guidelines REsearch and Evaluation-Recommendations Excellence Draft). Design Cross-sectional study Setting International CPG community. Participants Three hundred twenty-two international CPG developers, users, and researchers. Intervention Participants were assigned to appraise one of 161 CPGs selected for the study using the AGREE-REX-D tool Main outcome measures AGREE-REX-D scores of 161 CPGs (7-point scale, maximum 7). Results Recommendations from 161 CPGs were appraised by 322 participants using the AGREE-REX-D. CPGs were developed by 67 different organizations. The total overall average score of the CPG recommendations was 4.23 (standard deviation (SD) = 1.14). AGREE-REX-D items that scored the highest were (mean; SD): evidence (5.51; 1.14), clinical relevance (5.95; SD 0.8), and patients/population relevance (4.87; SD 1.33), while the lowest scores were observed for the policy values (3.44; SD 1.53), local applicability (3,56; SD 1.47), and resources, tools, and capacity (3.49; SD 1.44) items. CPGs developed by government-supported organizations and developed in the UK and Canada had significantly higher recommendation quality scores with the AGREE-REX-D tool (p < 0.05) than their comparators. Conclusions We found that there is significant room for improvement of some CPGs such as the considerations of patient/population values, policy values, local applicability and resources, tools, and capacity. These findings may be considered a baseline upon which to measure future improvements in the quality of CPGs.


2008 ◽  
Vol 3 (1) ◽  
Author(s):  
María Eugenia Esandi ◽  
Zulma Ortiz ◽  
Evelina Chapman ◽  
Marcelo García Dieguez ◽  
Raúl Mejía ◽  
...  

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