Adapting clinical practice guidelines to local context and assessing barriers to their use

The phase of adaptation assists in moving from selection of a topic to identification of specific clinical questions; in searching for, retrieving and assessing guidelines; in decisionmaking around adaptation; and in preparing the draft version of the adapted guideline. Assessment of the retrieved guidelines involves evaluation of their quality (i.e., using the AGREE [Appraisal of Guidelines Research and Evaluation] instrument9,23), currency (i.e., how up-to-date they are) and consistency (i.e., congruence of the recommendation with the underlying evidence). Assessment also consists of the examination of the acceptability (i.e., to clinicians and patients) and applicability (i.e., feasibility of applying recommendations) of the guidelines' recommendations within the proposed context of use. This evaluation provides an explicit basis for informed and transparent decision-making around the selection and modification of guidelines used as sources. This process can result in different alternatives ranging from adopting a guideline unchanged, to translation of language and adaptation of format, to modification and updating of single recommendations, to the production of a customized guideline based on various guidelines used as sources. The finalization phase includes external review, feedback from relevant stakeholders, and consultation with the developers of source guidelines. Establishing a process for updating the adapted guideline and writing the final document are the last stages. One of the more often-cited conceptual frameworks regarding barriers to use of knowledge in health care is the Clinical Practice Guidelines Framework for Improvement by Cabana and colleagues.25 This framework was based on an extensive search of the literature for barriers to adherence by physicians to clinical practice guidelines and was organized according to knowledge, attitudes and behaviour of physicians.26 Of 5658 potentially eligible articles, Cabana and colleagues identified 76 published studies describing at least one barrier to adherence to clinical practice guidelines. The included articles reported on a total of 293 potential barriers to adherence to guidelines by physicians. These barriers included unawareness of the existence of the guideline (n = 46), unfamiliarity with the recommendations of guidelines (n = 31), disagreement with the recommendations (n = 33), lack of self-efficacy (i.e., feeling one is unable to carry out the recommendations) (n = 19), outcome exp