What are the strengths and limitations of currently used adaptation methods? Expert Consultation on Adapting WHO Guidelines organized by
AUB GRADE Center Beirut, Lebanon 30-31 May 2016
Objective • Describe the strengths and limitations of adaptation methods
Methods • We included – Guideline adaptations that reported any strength or limitation of adaptation – Review papers about adaptation: included any strength or limitation of adaptation
Methods 221 Papers
18 Review papers
Theoretical strengths and limitations
20 Guideline adaptations Actual experience strengths and limitations
Findings • Only 1 paper reporting on challenges with adapting WHO 2010 recommendations on treating pregnant women infected with HIV and PMTCT
Findings Specific strengths of adaptation reported • Efficient and effective • Avoids duplication of efforts • Identification of gaps that may not address regional issues • Improve acceptance/adherence/uptake of guidelines by taking into account local settings
Findings Specific strengths of adaptation methods • Appraisal of evidence assists panel members’ decisions • Added legitimacy • Helped in reaching consensus • Help in filtering large amount of information (by selecting good quality) • Adds rigor to the adaptation process
• Stakeholders as participants: helped select meaningful outcomes
Findings Specific strengths of adaptation methods (cont’d) • Analysis of content: identification of appropriate recommendations for local setting • External review by experts increased confidence in the appropriateness of adaptation • Including patient preference
Findings Specific limitations/challenges to guideline adaptation • Risk of modifying recommendations to suit a specific local setting (transmuting knowledge) • How is the change of recommendation ideally done? • Lack of evidence to support change of recommendation (quantity and quality) • Requires large complementary literature search • Evaluation/adaptation of various levels of recommendations
Findings Specific limitations/challenges to guideline adaptation • Including patients in the development group • Language barriers • Cultural hierarchical barriers (patients vs healthcare professionals) • Limited healthcare fluency
• Lack of sufficient evidence-based studies in countries adapting recommendations
Findings Specific limitations/challenges to guideline adaptation • Lack of methodologic quality of source guidelines/low quality: “Guidelines not fully comprehensive to answer all questions”
• Adaptation not feasible due to considerable amount of information published
Findings Specific limitations/challenges to guideline adaptation • Choosing different options for treatment by technical working groups (WHO adaptation of HIV guidelines: different 1st line ART regimen)
• Implementation not guaranteed ( require methodological expert)
Findings ADAPTE Strengths (Conceptual)
Limitations
Scientific and rigorous
No sufficient details on skills and organization requirements
Good healthcare quality outcomes
Fulfilling ADAPTE steps required time and expertise
Adaptation to local context
Subjective views of external panels
Implications • Need to reduce challenges in adaptation (more frequently reported than strengths by guideline adaptations) • This requires a more robust method of adaptation that can safely adapt recommendations from one setting to another.
Acknowledgment • • • • • • • • • •
Andrea J. Darzi, MD, MPH • Mohammad W. Godah, MD, MPH • Lama Kilzar, BS Chantal Lakis, MSc. Arnav Agarwal, BHSc Elias Abou-Jaoude, BS Joerg J Meerpohl, MD Wojtek Wiercioch, MSc Nancy Santesso, RD, MLIS, PhD Hneine Brax, MD
Holger Schünemann, MD, PhD Elie A. Akl, MD, MPH, PhD
