Diversity in clinical guidelines: the role of repertoires of evaluation

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Abstract

Clinical practice guidelines are one of the main tools by which clinicians, policy makers and patients hope to make health care less variable, more reliable and efficient, but there is little understanding of the processes by which clinical guidance is put together by guideline groups. This paper describes the social organisation of knowledge within clinical practice guideline development processes by drawing on the sociology of situated judgement. Two guideline development processes were observed, and the development group meetings (N=21) recorded and analysed qualitatively. Data analysis suggested that clinical guidance comes to existence through the combination of repertoires of evaluation, organised around four different epistemic criteria: robustness, usability, acceptability and adequacy. This research provides a detailed and layered understanding of the knowledge dynamics involved in developing recommendations for appropriate health care for specific clinical circumstance.

Introduction

Defined as ‘systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances’(Field & Lohr (Eds.), 1990), clinical practice guidelines (CPG) are presently one of the main tools through which clinicians, policy makers and patients hope to make health care less variable, more reliable and efficient. While clinical guidelines have been developed in western countries since the second half of the 20th century, the last decade has heightened their appeal as tools for supporting health care practice and policy. In the UK, the National Institute for Clinical Excellence is a Special Health Authority within the National Health Service that provides primary and acute care trusts, patients and clinicians with guidance on ‘best practice’, addressing the clinical management of specific conditions.

This strengthened interest in clinical guidelines can be linked with structural and epistemic alterations in contemporary health systems: a shift from provider-driven to buyer-driven health care delivery, and the emergence of managed care (Light, 2000); correlated shifts in the position of the medical profession and its regulation within health care systems in the UK (Harrison, 1996); and transformations in the organisation and understanding of medical knowledge and practice, particularly with the emergence of evidence-based medicine (EBM) in the 1990s (Sackett, Haynes, Guyatt, & Tugwell, 1991; Sackett, Rosenberg, Muir Gray, Haynes, & Richardson, 1996). Clinical guidelines have followed the EBM lead by adapting consensus-based development procedures to the requirements of secondary research (systematic reviews, meta-analysis, etc.) (Eccles & Grimshaw, 2000; Lohr, Eleazer, & Mauskopf, 1998). This adaptation has demanded the creation of ‘robust methodologies’ of guideline development with an increasing interest in understanding the factors that influence the development and implementation of guidelines (Berg, ter Meulen, & van den Burg, 2001; Berkwits, 1998).

The research here presented addresses the following question: how do guideline development groups put together their recommendations for appropriate health care for specific clinical circumstance? Drawing on qualitative analysis of guideline development meetings, this paper argues that in the construction of clinical guidance CPG groups attend to different sets of epistemic concerns organised around recursive forms of judgement (Thevenot & Boltanski, 2000). Data analysis identified four mains types of collective judgement by which CPG development groups endorse clinical guidance: the technical robustness of knowledge, its usability, political acceptability and its methodological adequacy.

The paper draws on the sociology of situated judgement of Boltanski and Thevenot (Boltanski & Thévenot, 1991) and the social studies of science, technology and medicine (Berg & Mol, 1998) in exploring how the diversity of knowledges is important in the development of medical standards such as guidelines. In the biomedical domain, more specifically, there has been an increasing awareness the multifarious knowledge worlds within biomedicine (Barbot & Dodier, 2002). The paper suggests that clinical guidance comes to existence through the combination of repertoires of evaluation of knowledge that are usually described by practitioners as not easily merged—‘biomedical science’ and ‘clinical practice’(Smith & Egger, 1998)—or recommended to stay apart—‘biomedical science’ and ‘health politics’. Acknowledging the diversity of forms of knowledge in the construction of clinical guidance might be a fundamental step in understanding the reported lack of impact of CPGs (Cabana et al., 1999) and is furthermore vital to achieve transparency in evidence based health care practice.

Section snippets

Method

Between 2002 and 2003, two guideline development processes were studied in their entirety, using a multiplicity of qualitative techniques. The groups, convened in an English University, were multidisciplinary, and of the total 20 participants. Two consultants per group, four general practitioners per group, two patients representatives in Group 1 and one in Group 2, one pharmacists per group, one nurse practitioner and one health services researcher in Group 1, and one methodologist acting in

The multiple ‘worlds’ of a guideline

The practice of evidence-based CPG development is nowadays an institutionalised procedure. Based upon the interaction between two units—a multidisciplinary development group and a research and support team—this process is aimed at facilitating the group's evaluation of the information requirements for appropriate clinical practice.1 The

The repertoire of ‘science’: technical robustness

Guideline groups’ attention to the criteria of reliability of the knowledge they produce and/or endorse is managed through their orientation towards a specific field and its form of discourse. This field is usually designated by group members as ‘science’. The robustness of a statement is evaluated by its possible resistance to critique by other researchers and/or guidelines developers. The resistance to possible critique is thus imagined in relation to a field of action that is dominantly

The repertoire of ‘practice’: usability

Guideline groups’ attention to the criteria of usability of the knowledge they produce and/or endorse is managed through their orientation towards a mode of discourse that has ‘practice’ as its central figure. The usability of a statement is evaluated by discussing its concrete usefulness in typical situations of doctor–patient interaction. In order to evaluate the ‘practice’ worth of a statement, members estimate (a) whether or not the statement proposes a change to the dominant health care

The repertoire of ‘politics’: acceptability

When judging the relative importance of information included in a clinical guideline, guideline groups also assess how acceptable it is to endorse statements or recommendations. The acceptability of a statement is evaluated by discussing how it might affect what members see as the relevant distributions of power in the institutions in which the guideline is going to be implemented. The repertoire of politics has to do with the collaborative evaluation of the political sensibleness of evidence

The repertoire of process: methodological adequacy

Guideline development group's evaluation of the knowledge endorsed in the document is also concerned with its own conditions of production. Their orientation towards the group as an apparatus of knowledge construction figures at the core the criteria of adequacy. In these types of situation, the quality of knowledge claims is seen as connected to the procedures—methods, discussions, etc.—through which it was elaborated. In this repertoire of evaluation, guideline groups make visible, orientate

Conclusion

The research presented here suggests a picture of evidence-based CPGs and their development that is different from the one frequently disseminated. Most guideline research has been mainly focused on the methodological aspects of recommendation development or, more recently, on the group processes (Pagliari & Grimshaw, 2002) and normative assumptions (Berg, ter Meulen, & van den Burg, 2001) that support such development. Through the theoretical approach that underpinned this study, it was

Acknowledgments

Drafts of this paper were presented at the SATSU ‘Brown Bag’ Seminar Series, University of York, in April 2003, and at the BSA MedSoc Group 35th Annual Conference, University of York, 26–28 September 2003. I thank the participants of both sessions for lively discussions, Richard Tutton for the invitation and Andrew Webster for his encouraging comments. For their generous comments I thank Nicolas Dodier, Neil Jenkins, James Mason, Carl May, Jeanette Pols, Tim Rapley, Dick Willems and the members

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