Clinical Practice Guidelines
Research & Education Perspectives
Susan Rappolt
Department of Occupational Therapy
University of Toronto
s.rappolt@utoronto.ca
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
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
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
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)
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
Accepted View of Professional Expertise in
Client-Centred Evidence-Based Practice
Pro fe ssi o n a l
Exp e rti se
Clinic a l
De c is ion
M a k ing
Cl i e n t
Evi d e n ce
Re se a rch
Evi d e n ce
Re-thinking Professional Expertise
in Client-Centred Evidence-Based Practice
The Role of Professional Expertise in CCEP
Stage 1
Client
Evidence
C
L
I
E
N
T
1. Gather and
appraise client
evidence
2. Identify
occupational
performance
issues
Stage 2
Research
Evidence
Stage 3
Integration of
Evidence
Stage 4
DecisionMaking
1. Identify
problem and
research
question
1. Establish
applicability and
appropriateness
1. Discuss
evidence with
client
2. Gather
relevant
evidence
2. Determine
method
2. Develop
collaborative
plans for
intervention
3. Appraise
quality of
evidence
Collaborative
Role
Professional
Role
Professional
& Client
Research
Expertise
3. Identify
evaluation criteria
Stage 5
Enablement
and Evaluation
1. Further
assessments as
needed
2. Undertake
processes for
enablement
3. Evaluate
outcomes
4. Anticipate
outcomes
Professional
Role
Collaborative
Role
Clinical
Expertise
Professional
& Client
Collaborative
Role
Professional &
Client
SPECIFIC CONTEXT OF PRACTICE
O
U
T
C
O
M
E
Revised Role of Professional Expertise
in Client-Centred Evidence-Based Practice
P r of essi onal
E xper t i se
Clinical Practice Guidelines
C l i ent
E vi dence
Clinical
Decision
Making
R esear ch
E vi dence
Functions of CPGs

For the Client:

Transparent treatment plans for informed
collaborative decision-making

Fosters best possible clinical practice

Promotes best possible clinical outcomes
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
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
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
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
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
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
How to Evaluate a CPG:






Defined scope and purpose
Stakeholder involvement
Rigorous development
Clear and well presented
Applicability
Editorial independence
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
Experiences of Other
Professions with CPGs

Physiotherapy

Nursing

Medicine
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
Clinical Practice Guidelines?

What are the alternatives?