“It’s Not Smooth Sailing”: Bridging the Gap Between Methods and Content Expertise in Public Health Guideline Development

Document Type : Original Article

Authors

1 Charles Perkins Centre, Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, NSW, Australia

2 Faculty of Nursing, University of Toronto, Toronto, ON, Canada

Abstract

Background
The development of reliable, high quality health-related guidelines depends on explicit and transparent processes, methods aimed at minimising risks of bias and the inclusion of all relevant expertise and perspectives. While the methodological aspects of guidelines have been a focus to improve their quality, less is known about the social processes involved, for example, how guideline group members interact and communicate with one another, and how the evidence is considered in informing recommendations. With this in in mind, we aimed to empirically examine the perspectives and experiences of the key participants involved in developing public health guidelines for the Australian National Health and Medical Research Council (NHMRC).

 
Design
This study was conducted using constructivist grounded theory as described by Charmaz, which informed our sampling, data collection, coding and analysis of interviews with key participants involved in developing public health guidelines.

 
Setting
Australian public health guidelines commissioned by the NHMRC. 
 
Participants
Twenty experts that were involved in Australian NHMRC public health guideline development, including working committee members with content topic expertise (n = 16) and members of evidence review groups responsible for evaluating the evidence (n = 4).

 
Results
Public health guideline development in Australia is a divided process. The division is driven by 3 related factors: the divergent disciplinary background and expertise that each group brings to the process; the methodological limitations of the framework, inherited from clinical medicine, that is used to assess the evidence; and barriers to communication between content experts and evidence reviewers around respective roles and methodological limitations.

 
Conclusion
Our findings suggest several improvements for a more functional and unified guideline development process: greater education of the working committee on the methodological process employed to evaluate evidence, improved communication on the role of the evidence review groups and better facilitation of the process so that the evidence review groups feel their contribution is valued.

Keywords


  1. Institute of Medicine Committee (IOM). Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press. 2011.
  2. Blake P, Durao S, Naude CE, Bero L. An analysis of methods used to synthesize evidence and grade recommendations in food-based dietary guidelines. Nutr Rev. 2018;76(4):290-300. doi:10.1093/nutrit/nux074
  3. World Health Organisation (WHO). WHO Handbook for Guideline Development. 2nd ed. Geneva, Switzerland: WHO; 2014.
  4. National Institute for Health and Care Excellence (NICE). Developing NICE guidelines: the manual. Introduction and overview. https://www.nice.org.uk/process/pmg20/chapter/glossary#standing-committee.  Accessed 31 March, 2019. Published 2014.
  5. Department of Health and Human Services. United States Community Preventive Services Task Force. The Community Guide. https://www.thecommunityguide.org/. Published 2016.
  6. National Health and Medical Research Council (NHMRC). 2016 NHMRC Standards for Guidelines. https://www.nhmrc.gov.au/about-us/publications/2016-nhmrc-standards-guidelines . Accessed March 31, 2019. Published 2016.
  7. National Health and Medical Research Council. Guidelines for Guidelines. https://www.nhmrc.gov.au/guidelinesforguidelines/background.  Accessed March 31, 2019. Published 2018.
  8. Balshem H, Helfand M, Schünemann HJ, et al. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol. 2011;64(4):401-406. doi:10.1016/j.jclinepi.2010.07.015
  9. National Institute for Health and Care Excellence (NICE). Types of guideline. https://www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/nice-guidelines/types-of-guideline . Accessed 31 March, 2019. Published 2016.
  10. National Health and Medical Research Council (NHMRC). NHMRC Statement: Evidence on Wind Farms and Human Health. https://www.nhmrc.gov.au/health-advice/environmental-health/wind-farms.  Accessed May 23, 2019. Published 2015.
  11. National Health and Medical Research Council (NHMRC), Department of Health and Ageing. Australian Dietary Guidelines. Canberra: Commonwealth of Australia, NHMRC; 2013.
  12. Norris SL, Bero L. GRADE methods for guideline development: time to evolve? Ann Intern Med. 2016;165(11):810-811. doi:10.7326/m16-1254
  13. Rehfuess EA, Akl EA. Current experience with applying the GRADE approach to public health interventions: an empirical study. BMC Public Health. 2013;13:9. doi:10.1186/1471-2458-13-9
  14. Burgers JS, Bailey JV, Klazinga NS, Van Der Bij AK, Grol R, Feder G. Inside guidelines: comparative analysis of recommendations and evidence in diabetes guidelines from 13 countries. Diabetes Care. 2002;25(11):1933-1939. doi:10.2337/diacare.25.11.1933
  15. Raine R, Sanderson C, Hutchings A, Carter S, Larkin K, Black N. An experimental study of determinants of group judgments in clinical guideline development. Lancet. 2004;364(9432):429-437. doi:10.1016/s0140-6736(04)16766-4
  16. Pagliari C, Grimshaw J. Impact of group structure and process on multidisciplinary evidence-based guideline development: an observational study. J Eval Clin Pract. 2002;8(2):145-153. doi:10.1046/j.1365-2753.2002.00333.x
  17. Atkins L, Smith JA, Kelly MP, Michie S. The process of developing evidence-based guidance in medicine and public health: a qualitative study of views from the inside. Implement Sci. 2013;8:101. doi:10.1186/1748-5908-8-101
  18. Alexander PE, Gionfriddo MR, Li SA, et al. A number of factors explain why WHO guideline developers make strong recommendations inconsistent with GRADE guidance. J Clin Epidemiol. 2016;70:111-122. doi:10.1016/j.jclinepi.2015.09.006
  19. Alexander PE, Li SA, Gionfriddo MR, et al. Senior GRADE methodologists encounter challenges as part of WHO guideline development panels: an inductive content analysis. J Clin Epidemiol. 2016;70:123-128. doi:10.1016/j.jclinepi.2015.09.003
  20. Charmaz K. Constructing Grounded Theory: A Practical Guide Through Qualitative Analysis. London: SAGE Publications; 2006.
  21. National Health and Medical Research Council (NHMRC). Guidelines for Guidelines. Plan; Guideline development group. https://www.nhmrc.gov.au/guidelinesforguidelines/plan/guideline-development-group.  Accessed May 20, 2019.
  22. Creswell J. Qualitative Inquiry and Research Design: Choosing Among Five Approaches. London: SAGE Publications; 2007.
  23. Sturges JE, Hanrahan KJ. Comparing telephone and face-to-face qualitative interviewing: a research note. Qual Res. 2004;4(1):107-118. doi:10.1177/1468794104041110
  24. Mason J. Qualitative Researching. 2nd ed. London: SAGE Publications; 2002.
  25. Akl EA, El-Hachem P, Abou-Haidar H, Neumann I, Schünemann HJ, Guyatt GH. Considering intellectual, in addition to financial, conflicts of interest proved important in a clinical practice guideline: a descriptive study. J Clin Epidemiol. 2014;67(11):1222-1228. doi:10.1016/j.jclinepi.2014.05.006
  26. Viswanathan M, Carey TS, Belinson SE, et al. A proposed approach may help systematic reviews retain needed expertise while minimizing bias from nonfinancial conflicts of interest. J Clin Epidemiol. 2014;67(11):1229-1238. doi:10.1016/j.jclinepi.2014.02.023
Volume 9, Issue 8
August 2020
Pages 335-343
  • Receive Date: 04 June 2019
  • Revise Date: 28 October 2019
  • Accept Date: 11 December 2019
  • First Publish Date: 01 August 2020