CREATING GUIDELINES THAT ADAPT TO LOCAL CONTEXTS

描述（改编自摘要）： 临床指南被提倡作为提高护理质量的一种手段， 减少实践中的差异，提高护理的成本效益。 然而，准则的接受程度及其对实践的实际影响， 被限制。 两个明显自相矛盾的属性，不精确的 建议和明确规定的建议（不适用于当地 实践或特定患者群体），已被发现是重要的 不遵守准则的原因。 我们假设， 这个问题是以一种关注目标的方式来设计指导方针 而不是针对具体机构或具体情况的做法， 在当地环境中适应后者。 我们建议开发一个正式的方法来创作设置独立 临床指南，并使其适应特定的临床环境 患者人群。 专业协会以及区域、国家或 国际组织可以利用这一方法创造环境- 独立的指导方针。 卫生保健机构，如医院、诊所和 实践小组可以通过调整这些指导方针来适应他们的环境， 准则所载的建议和决定标准， 适当的本地设置。 在每个决策点，不同的管理层 选项可以沿着说明使用的基本原理和注意事项， 不同亚组的患者。 准则将以分级方式规定，即，准则将 可以递归地分解为子指南，子指南可以进一步分为 其他子指南。 更高级别的子指南将指定条件， 在目标方面，以"有意识"的方式采取行动（如"减少" 收缩压"），而不是"扩展"，在特定的方面， 实现目标的方法（例如，"给予β-受体阻滞剂"）。 模型 将包含约束的规范，这些约束可应用于 设置独立指南的子指南。 这些限制 允许在适应过程中对指南进行修改， 独立设置指南的完整性。 我们将进行一个形成性研究，以了解有关创作的问题 使用这种方法的指南。 设置独立的准则将是 在初级保健实践中产生的问题。 这些指导方针将 适合于特定的初级保健临床环境。 的潜在影响 在实践中遵守准则的这种方法也将 评估。 我们将比较 为接受所载建议而调整的准则 没有被改编的指南。

DESCRIPTION (adapted from the Abstract): Clinical guidelines are advocated as a means to improve quality of care, reduce variations in practice, and increase cost-effectiveness of care. However, acceptance of guidelines and their actual impact on practice have been limited. Two apparently self-contradictory attributes, imprecise recommendations and well-specified recommendations (inapplicable in a local practice or to specific groups of patient), have been found as important causes of poor compliance with guidelines. We hypothesize that a solution to this problem is to design guidelines in a manner that focuses on objectives rather than institution-specific or context-specific practices, which can then be adapted to the latter in local settings. We propose to develop a formal methodology for authoring setting-independent clinical guidelines and for adapting them to specific clinical environments and patient populations. Professional societies, and regional, national, or international organizations can utilize this methodology to create setting- independent guidelines. Health care settings such as hospitals, clinics, and practice groups can adapt these guidelines to their contexts by adapting recommendations and decision criteria contained in the guideline to those local settings appropriately. At each decision point, different management options can be specified along with rationale and considerations for use in different subgroups of patients. Guidelines will be specified in a hierarchical manner, i.e., guidelines will be decomposed recursively into subguidelines that may be further divided into other subguidelines. Higher level subguidelines will specify conditions and actions in an "intentional" manner, in terms of objectives (like "reduce systolic blood pressure") rather than "extensionally," in terms of particular approaches to achieving the objective (e.g., "give beta-blocker"). The model will contain a specification for constraints that can be applied to subguidelines of setting-independent guidelines. These constraints limit allowed modifications to a guideline during adaptation in order to preserve the integrity of the setting-independent guideline. We will conduct a formative study to understand issues pertaining to authoring guidelines using this approach. Setting-independent guidelines will be created for problems in primary care practice. These guidelines will then be adapted to a particular primary care clinical setting. The potential impact of this approach on adherence to guidelines in that practice will also be evaluated. We will compare the acceptance of recommendations contained in guidelines that have been adapted to acceptance of recommendations contained in guidelines that have not been adapted.