Using Guidelines:
The Need for Adaptation
Ian D Graham, PhD, FCAHS
December 10, 2012
E-GAPPS
Disclosures
• No relationships with industry
• Co-editor of Knowledge Translation in Health Care
(2009)- all royalties go to students
• Co-creator of K2A Cycle, Ottawa Model of Research
Use, Practice Guideline Evaluation and Adaptation
Cycle
• Founding member of ADAPTE Collaboration
• Advisor to CAN-IMPLEMENT
• Acknowledgements: CAN-IMPLEMENT for
permission to use some of their slides
Session will cover
• What is guideline adaptation
• Why the need for adaptation
• Some approaches to adaptation
The Challenge
Guideline ADAPTATION
A systematic process that guides local
groups to identify, evaluate, adapt and use
already available guidelines for their own
purposes.
Done for two major reasons, to facilitate:
• guideline development
• guideline implementation
Guideline ADAPTATION:
Done for Development Purposes
 An alternative to de novo development which requires
extensive search and synthesis of primary research
data
 Reduces duplication of effort while maintaining the
validity of recommendations
 Increases knowledge and commitment to evidencebased principles by using reliable methods to ensure
quality and validity
 Promotes explicitness and transparency in documenting
recommendations
Guideline ADAPTATION:
Done for Implementation Purposes
• When an existing guideline does not completely
address a setting’s clinical question (adapt from 1
or multiple guidelines to create an adapted de novo
guideline that addresses the clinical question)
• To prepare for implementing guideline
recommendations (prioritizing recommendations,
adapting language, aligning recommendation to context,
anticipating and addressing implementation barriers)
Guideline ADAPTATION:
Social Constructivist Theory
Participatory approach engaging key
stakeholders means:
-> focusing on the clinical question of interest
-> interactive problem solving
-> co-creating of knowledge
-> ownership of recommendations to be
implemented
-> ensuring consideration of contextual factors
to ensure relevance to practice in anticipation
of implementation
-> increasing likelihood of implementation
First Came the Practice Guideline and
Evaluating Cycle (1999-2005)
Developed working with regional group interested
in improving wound care in the community
Community of practice formed around adaptation
process
Action research, participatory style
Anticipated & dealt with blocks before they
became major barriers to implementation
Iterative process of using external evidence &
producing local ‘evidence’ for adaptation
Practice Guidelines Evaluation and Adaptation Cycle
1. Identify a Clinical Area to
Promote Best Practice
10. Scheduled Review and
Revision of Local Guideline
9. Official Endorsement
and Adoption of Local
Guideline
2. Establish an
Interdisciplinary Guideline
Evaluation Group
8. Finalize Local Guideline
3. Establish Guideline
Appraisal Process
7. External Review – Practioner
and Policy Maker Feedback;
Expert Peer Review
4. Search and Retrieve
Guidelines
6. Adaptation of Guidelines
for Local Use
5. Guidelines Assessment
a) Quality
b) Currency
c) Content
ADAPTE Collaboration
• Merging of ADAPTE group and PGEAC group
(Jan 2006)  international collaboration
• Members include guideline developers,
researchers, guideline implementers
• Concept, process housed with resources
– 12 page manual
– Detailed resource toolkit
– Web resources
• ADAPTE turned over to the GuidelineInternational-Network
Adaptation Phase
Set Up Phase
PHASES
TASKS
PREPARE FOR ADAPTE PROCESS
Preparation
DEFINE HEALTH QUESTIONS
Scope and
Purpose
SEARCH AND SCREEN GUIDELINES
Search
and
Screen
ASSESS GUIDELINES
DECIDE AND SELECT
DRAFT GUIDELINE REPORT
Finalization Phase
ASSOCIATED
MODULES
EXTERNAL REVIEW
PLAN FOR FUTURE REVIEW AND UPDATE
PRODUCE FINAL GUIDELINE
Assessment
Decision and
Selection
Customization
External
Review
Aftercare
planning
17
Final Production
The ADAPTE Collaboration
www.adapte.org
CAN-IMPLEMENT (2007-2011)
• Canadian Partnership Against Cancer Guideline
Action Group project
• 5 groups across Canada interested in guideline
adaptation to facilitate use of best practice
started with ADAPTE process that evolved and
expanded with experiential knowledge of
adaptation
• Adaptation process integrated with Knowledge
to Action Cycle
CAN-IMPLEMENT 3 Phase Methodology
PHASE
1
Identification
and Clarification
of
Issue/Problem
PHASE
2
Solution
Building
PHASE
3
Implementation,
Evaluation and
Sustainability
Key Points
 For those thinking implementation, guideline adaptation
marks the start of the process, is means to an end vs. the
end itself
 The participatory nature of adaptation fosters end-user
engagement in planning for implementation (creation of
community of practice around uptake of adapted guideline)
 The focus on alignment of guideline recommendations with
local context/evidence and interactive problem solving
regarding potential barriers and solutions to potential
resistance enhances ownership and implementation of the
adapted guideline
Knowledge, if it does not determine action,
is dead to us
Plotinus (Roman philosopher 205AD-270AD)