After criticizing our organization's well established evidence-informed,
consensus-based process of adapting clinical practice guidelines, I have
been tasked to make recommendations on how to make the adaptation of
existing clinical practice guidelines (primarily consensus-based) more
explicitly evidence-based.  In my first attempt at this effort, I presented
the SIGN methodology (SIGN publication #39) as a model and was informed that
our charter was to adapt guidelines, not to create guidelines.  I've been
searching for an appropriate model for adaptation since that time.

My colleagues and I, at Naval Hospital Jacksonville, developed an EBHC
skills seminar around dissection of the NHLBI Asthma guidelines.
Knowledgeable clinicians reviewed the guideline and developed a series of
key clinical questions (in this case as a teaching tool  designed to
demonstrate that (1) some of the guideline recommendations were clearly
supported by good evidence, (2) other strong recommendations were supported
by weak evidence and (3) some strongly worded recommendations went against
the evidence for effectiveness).  We then used the Clinical Queries feature
of PubMed and the Catnipper software to take the participants through the
process of searching the primary source literature online, evaluating the
abstracts for relevance, the articles for validity and documenting their
findings as a CAT.  The final session took the participants through the same
process using the TRIP search engine to identify Cochrane reviews and other
high quality evidence-based reviews.  The "ah ha" experience for these
healthcare administrators was that they could access high quality
information relatively easily.  The syllabus for our course was placed on a
CD-Rom which can be viewed at http://nhso/code03/ebhc.htm for anyone who
might be interested.

My questions to the group - 

(1) Does anyone have a model for adapting consensus-based guidelines of
varying quality using an evidence-based approach?  

(2) Does the approach that we used for teaching EBHC skills seem like a
reasonable model for adaptation of existing guidelines?  Please make
recommendations.

	The outline of my proposed model is:

*	Seed guideline (varying quality) is reviewed and key clinical
questions are developed.
*	Key clinical questions are searched in an iterative process similar
to that described in SIGN publication 39 searching the Cochrane Library on
disk first, then using the TRIP search engine and finally the Clinical
Queries feature of PubMed to efficiently identify high quality reviews
and/or appropriate high quality studies.
*	Use of the Catmaker(R) software to appraise and catalog the evidence
relating to the key questions.
*	Creation of evidence summaries from this catalog of evidence. 
*	Grading the evidence.
*	Development of graded recommendations from the evidence summaries.
*	Development of an adapted guideline, decision support tools and
metrics based on the graded recommendations.

I greatly appreciate any and all input from the group.

Very Respectfully,  Chip Taylor, MD



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