Guideline harmonization and implementation plan for the BETTER trial: Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Family Practice
Background The aim of the Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Family Practice (BETTER) randomized controlled trial is to improve the primary prevention of and screening for multiple conditions (diabetes, cardiovascular disease, cancer) and some of the associated lifestyle factors (tobacco use, alcohol overuse, poor nutrition, physical inactivity). In this article, we describe how we harmonized the evidence-based clinical practice guideline recommendations and patient tools to determine the content for the BETTER trial.
Methods We identified clinical practice guidelines and tools through a structured literature search; we included both indexed and grey literature. From these guidelines, recommendations were extracted and integrated into knowledge products and outcome measures for use in the BETTER trial. End-users (family physicians, nurse practitioners, nurses and dieticians) were engaged in reviewing the recommendations and tools, as well as tailoring the content to the needs of the BETTER trial and family practice.
Results In total, 3–5 high-quality guidelines were identified for each condition; from these, we identified high-grade recommendations for the prevention of and screening for chronic disease. The guideline recommendations were limited by conflicting recommendations, vague wording and different taxonomies for strength of recommendation. There was a lack of quality evidence for manoeuvres to improve the uptake of guidelines among patients with depression. We developed the BETTER clinical algorithms for the implementation plan. Although it was difficult to identify high-quality tools, 180 tools of interest were identified.
Interpretation The intervention for the BETTER trial was built by integrating existing guidelines and tools, and working with end-users throughout the process to increase the intervention’s utility for practice. Trial registration: ISRCTN07170460
Most of the health care activities for improving the prevention of and screening for chronic diseases are implemented in family practice. About 7.4 hours per day of provider time are required to deliver all manoeuvres recommended within current practice structures. Because of the multiple demands of family practice, this is not feasible. Primary care practitioners also require effective strategies to concurrently address multiple conditions, because 45% of people have more than one chronic disease. In particular, depression — a prevalent comorbidity in family practice — is associated with poor uptake of prevention and screening manoeuvres. Therefore, promoting practice organization that delivers prevention and screening in an effective and time-efficient manner is a priority.
Cardiovascular disease, diabetes and breast, colorectal and cervical cancer, as well as their associated lifestyle risk factors (e.g., tobacco use, alcohol overuse, poor nutrition, physical inactivity), are prevalent in primary care. There are evidence-based recommendations for the prevention of and screening for these conditions, and following these recommendations can reduce morbidity and mortality. However, there are dozens of clinical practice guidelines with recommendations for each of these conditions, which creates a substantial challenge for providers. This is one of the reasons why the effectiveness of guidelines as tools to facilitate the translation of evidence into practice has been inconsistent.
The harmonization of guidelines and their integration into an implementation plan represent important first steps in addressing this issue. In this article, we describe the process by which we harmonized recommendations from clinical practice guidelines and implementation tools for the target conditions. The results of this process were used to inform the interventions in the Building on Existing Tools to Improve Primary Prevention and Screening in Family Practice (BETTER) randomized controlled trial.