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Clinical Practice Guidelines. Research & Education Perspectives. Susan Rappolt Department of Occupational Therapy University of Toronto Clinical Practice Guidelines . Definition:

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clinical practice guidelines

Clinical Practice Guidelines

Research & Education Perspectives

Susan Rappolt

Department of Occupational Therapy University of Toronto

clinical practice guidelines1
Clinical Practice Guidelines
  • Definition:

A systematically developed statement designed to assist clinician and patient decisions about appropriate health care for specific clinical circumstances

Field and Lohr, 1990

When written carefully, CPGs can offer guidance on treatment options based upon the established effectiveness of available therapeutic options (including no treatment), a patient’s individual clinical situation, minimization of harm, and cost.

Green & Piehl, 2003

evidence based practice
Evidence-Based Practice

Evidence-based practice (EBP) is like a toolbox of methods available to the occupational therapy practitioner to aid clinical reasoning. The toolbox consists primarily of methods designed to integrate current and best evidence from research studies into the clinical reasoning process.

Tickle-Degnen, 2000

the ebp toolbox
The EBP “Toolbox”
  • Expert opinion, consensus panels
  • Research papers (CAPS - critically appraised papers)
  • Systematic Reviews (CATS: critically appraised topics)
  • Clinical practice guidelines (short-cuts to evidence)
decision making in client centred practices
Decision Making in Client-Centred Practices
  • Client evidence
  • Research evidence
  • Professional Expertise:
    • Knowledge of the context and resources
    • Knowledge of own scope and skill level

Accepted View of Professional Expertise in

Client-Centred Evidence-Based Practice


Re-thinking Professional Expertise

in Client-Centred Evidence-Based Practice

Stage 2

Research Evidence

Stage 4


Stage 1

Client Evidence

Stage 3

Integration of Evidence

Stage 5

Enablement and Evaluation

1. Discuss evidence with client

1. Identify problem and research question

1. Establish applicability and appropriateness

1. Gather and appraise client evidence

1. Further assessments as needed

2. Undertake processes for enablement

2. Gather

relevant evidence

2. Develop collaborative plans for intervention

2. Identify occupational performance issues

2. Determine method

3. Evaluate outcomes

3. Appraise quality of evidence

3. Identify evaluation criteria

4. Anticipate outcomes



The Role of Professional Expertise in CCEP



Collaborative Role

Collaborative Role

Clinical Expertise

Professional & Client

Professional & Client

Professional & Client




















Revised Role of Professional Expertise

in Client-Centred Evidence-Based Practice

Clinical Practice Guidelines

functions of cpgs
Functions of CPGs
  • For the Client:
    • Transparent treatment plans for informed collaborative decision-making
    • Fosters best possible clinical practice
    • Promotes best possible clinical outcomes
functions of cpgs1
Functions of CPGs
  • For the Therapist:
    • Guide for practice
    • Efficient short-cut to evidence
    • Enhances validity of treatment approach for clients, regulators and payers
    • Enhances credibility for marketing services
functions of cpgs2
Functions of CPGs
  • For the Profession:
    • Formalizes a general practice process within a clinical domain
    • Facilitates development of knowledge repertoire of profession
    • Provides credibility in negotiations with payers
functions of cpgs3
Functions of CPGs
  • Legal functions:
    • CPGs could be used with expert testimony to aid in determining the standard of care
    • Expert testimony is used to determine the applicability of the CPG to the particular case.

McDonagh, Lavis & Sharpe, 2002

functions of cpgs4
Functions of CPGs
  • For Payers:
    • Serve as guidelines for when to refer to OT
    • Provide justification for allocation of resources
    • Can be misused to constrain service utilization and control costs
functions of cpgs5
Functions of CPGs
  • For Researchers:
    • CPGs provide a common protocol for studies of treatment effectiveness in improving client outcomes
    • Results of studies of treatment effectiveness are used to validate or revise CPGs
how are cpgs developed
How are CPGs developed?
  • Determine topic
  • Assemble stakeholders
  • Assemble and evaluate evidence
  • Collaboratively produce guidelines
  • Disseminate guidelines
    • (full, abridged and consumer versions)
  • Evaluate the impact of the guidelines
  • Revise guideline as needed
how to evaluate a cpg
How to Evaluate a CPG:
  • Defined scope and purpose
  • Stakeholder involvement
  • Rigorous development
  • Clear and well presented
  • Applicability
  • Editorial independence
effectiveness of cpgs in improving clinical outcomes
Effectiveness of CPGs in Improving Clinical Outcomes:

“…some evidence that guideline-driven care can be effective in changing the process and outcome of care provided by professions allied to medicine.”

Thomas, Cullum, McColl, Rousseau, Soutter & Steen, 2005

experiences of other professions with cpgs
Experiences of Other Professions with CPGs
  • Physiotherapy
  • Nursing
  • Medicine
experiences of other ot organizations with cpgs
Experiences of Other OT Organizations with CPGs
  • American Association of Occupational Therapists (AOTA)
  • National Association of Rheumatology Occupational Therapists (NAROT)
  • CAOT: Guidelines for Client-Centred Practice
clinical practice guidelines2
Clinical Practice Guidelines?
  • What are the alternatives?