Transparency matters: Kaiser Permanente's National Guideline Program methodological processes

Abstract

Introduction: The practice-guideline process of collecting, critically appraising, and synthesizing available evidence, then developing expert panel recommendations based on appraised evidence, makes it possible to provide high-quality care for patients. Unwanted variability in the quality and rigor of evidence summaries and Clinical Practice Guidelines has been a long-standing challenge for clinicians seeking evidence-based guidance to support patient care decisions.

Methods: A multidisciplinary group of stakeholders, with representation from all eight Kaiser Permanente Regions, is responsible for creating National Guidelines. Conducting high-quality systematic reviews and creating clinical guidelines are time-, labor-, and resource-intensive processes, which raises challenges for an organization striving to balance rigor with efficiency. For these reasons, the National Guideline Program elected to allow for the identification, assessment, and possible adoption of existing evidence-based guidelines and systematic reviews using the ADAPTE; Appraisal of Guidelines Research and Evaluation; Assessment of Multiple Systematic Reviews (AMSTAR); and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) frameworks. If no acceptable external guidelines are identified, the Guideline Development Team then systematically searches for relevant high-quality systematic reviews, meta-analyses, and original studies. Existing systematic reviews are assessed for quality using a measurement tool to assess systematic reviews (the AMSTAR systematic review checklist).

Study appraisal: Following the screening and selection process, the included studies (the "body of evidence") are critically appraised for quality, using the GRADE methodology, which focuses on four key factors that must be considered when assigning strength to a recommendation: balance between desirable and undesirable effects, quality of evidence, values and preferences, and cost. The evidence is then used to create preliminary clinical recommendations. The strength of these recommendations is graded to reflect the extent to which a guideline panel is confident that the desirable effects of an intervention outweigh undesirable effects (or vice versa) across the range of patients for whom the recommendation is intended.

Dissemination: The Care Management Institute disseminates all KP national guidelines to its eight Regions via postings on its Clinical Library Intranet site, a Web-based internal information resource.

Figures

Figure 1

The Institute of Medicine approach to systematic reviews and clinical practice guidelines. Reprinted with permission: Interactive figure available from: www.iom.edu/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust.aspx; click on “Launch graphic.”

Figure 2

The Kaiser Permanente approach to evidence-based practice.

Figure 3

Schematic representation of Kaiser Permanente's process for guideline creation. AGREE = Appraisal of Guidelines Research and Evaluation; AMSTAR = Assessment of Multiple Systematic Reviews; GRADE = Grading of Recommendations Assessment, Development, and Evaluation

Figure 4

Guideline implementation at Kaiser Permanente. CDS = clinical decision support; EHR = electronic health record; NCQA = National Committee for Quality Assurance