The Adapted ADAPTE approach to CPG adaptation proposed by the Alexandria Center for Evidence-Based Clinical Practice Guidelines, Alexandria University, Egypt. An oral presentation conducted by Prof. Tarek Omar during the national initiative of the Pediatrics Department, Armed Forces College of Medicine, themed; 'Towards National Guidelines' that was launched in 2018 and started by Pediatrics CPGs

1. ADAPTATION OF CLINICAL
PRACTICE GUIDELINES:
The Adapted ADAPTE Approach
Alexandria Center for Evidence-Based Clinical Practice
Guidelines
1
Prof. Tarek Omar
Professor & Head of Pediatric Neurology Unit,
Department of Pediatrics, Faculty of Medicine,
Founding Member & Supervisor, Alexandria Center
for Evidence-based Clinical Practice Guidelines,
Alexandria University
Dr. Yasser S. Amer
CPG Methodologist, CPG Unit, Quality Management
Department, King Khaled University Hospital,
Research Chair for Evidence-Based Health Care and
Knowledge Translation, King Saud University
Founding Member, Alexandria Center for Evidence-
based Clinical Practice Guidelines, Alexandria
University

2. Executive summary
 Based on the original ADAPTE Method: Guideline Adaptation
Resource Toolkit (Version 2.0) published by the Guidelines
International Network and former ADAPTE Collaboration.
Three phases: set-up, adaptation and finalization.
Nine modules and 24 steps.
 Included 3 modified tools, 3 new tools.
Alternatives for 4 steps to enhance utilization.
Suitable for healthcare contexts with limited resources.
2

3. Once upon a time in
Alexandria, Egypt ……!
3

4. Evidence-Based Clinical
Practice Guidelines
Adaptation
In Alexandria University
Hospitals in Alexandria, Egypt
4

5. Alexandria University Hospitals
Healthcare Quality Directorate
Center for Evidence-Based Clinical Practice
Guidelines
(AUH – HCQD, CEBCPGs)
(Founded Nov. 2008)
http://www.med.alexu.edu.eg/cebcpgs/
Member of Guidelines International Network (G-I-N)
(2009-2012)
5

6. 6

7. 7

8. G-I-N
Founded in Nov. 2002
8

9. First Workshop in Egypt:
Adaptation of CPGs
2009 (AFM-GIN-ADAPTE)
9
Founding Members
2008
Prof. Dr. Mahmoud Elzalabany
Prof. Dr. Tarek Omar
Prof. Dr. Nabil Dowidar
Prof. Dr. Afaf Ibrahim
Dr. Yasser S. Amer
Dr. Hossam Ashour
Eng. Ahmed Mourady

10. ADAPTE CPG Thesis/ Book Title (AUCH Library)
1. Acute Asthma, Treatment
2. Positioning & Attachment Breast Feeding Problems, Treatment
3. Hypoxic ischemic Encephalopathy, Treatment
4. ADHD, Treatment
5. Bacterial Meningitis, Management
6. Community Acquired Pneumonia, Treatment
7. First unprovoked epileptic seizure, Diagnosis
8. Chronic Asthma, Treatment
9. Autism Spectrum Disorders, Treatment
10. Epilepsy, Management – MD
11. Juvenile Rheumatoid Arthritis – MD
12. Cerebral Palsy, Treatment
Triage and Acuity Scale (A&E)
Acute organophosphorus poisoning (A&E)
10

12. http://qualitysafety.bmj.com/content/22/Suppl_1/43.1.abstract?sid=302fcfca-c444-
4bd3-a295-c75c811b7d49 (last cited 14/4/2018 in BMJ Quality & Safety)

13. Read
Adopt
Adapt
Develop
CPGs ?
Slide courtesy of Prof. Nabil Dowidar
13

14. CPG
Development (de novo)
vs. Adaptation
14

15. Main differences Develop vs. ADAPTE
ADAPTEDEVELOP (de novo)
AdaptationDevelopment (GDG) Working groups
Check whether
adaptation is feasible
then TEAM formation
Team formation Sequence of steps
(starting)
PIPOHPICO(T) Health/ Clinical
questions
CPGs
Or
CPGs and studies (if
mixed methods)
Primary/ secondary
studies
Evidence syntheses/
summaries
 Evidence Base
15

16. What is CPG adaptation?
“Guideline adaptation is the systematic
approach to the endorsement and/or modification of a
guideline(s) produced in one cultural and
organizational setting for application in a different
context. Where high quality guidelines are already
available, adaptation may be used as an alternative to
de novo guideline development to customize the
existing guideline to the needs of local users.”
The ADAPTE Collaboration (2006-2010)
16

17. Why CPG Adaptation?
• Proper development and updating of high-quality CPGs require
substantial time, expertise and resources.
• Need of HCOs to standardize health policies and practices to promote
optimal EBHC.
• Pressure on HCOs to produce CPGs rapidly, to ensure that medical
practice is consistent with current, emerging medical knowledge. This
work is often done with limited resources.
17

18. The ADAPTE postulates that . . . .
. . . . .existing high quality CPGs as a resource may be an alternative
to de novo development to reduce duplication of effort, enhance
efficiency, and promote local uptake of quality CPG
recommendations.
18

19. G-I-N Adaptation Working Group
19

20. G-I-N Arab

21. Regional: WHO-EMRO
Nov. 2015

22. Our method: The ‘Adapted
ADAPTE’
22

23. Published in 2015, Cited 11 times23

24. A methodological survey identified 8 frameworks
for adaptation of CPGs
Darzi AJ et al. J Clin Epi 2017 (AUB):-
ADAPTE (original), Adapted ADAPTE,
Alberta Program, GRADE-ADOLOPMENT,
MAGIC, RAPADAPTE, RCN, and SGR
24

25. WHY?
• To improve utilization of ADAPTE Guideline
Adaptation Resource Toolkit
25
Clarity
Simplicity
Practicality

26. Current Situation: Evidence to
Practice Gap
Lack of sufficient high quality research evidence for
regional public health problems
Barriers to implementation of evidence-based policies
Lack of human resources with knowledge translation (KT)
expertise
Conflicts of interests in research
Health research is an end-point
No specialized expert bodies for de novo GL development
26

27. 3 New Tools3 Modified Tools
For the Guideline Adaptation: A Resource Toolkit Version 2.0
27

28. 3 Phases, 9 Modules, 23 Steps
(based on the original ADAPTE)
28

29. 29

30. Phase 1: Set Up
1.1. Preparation Module
Step 1. check whether adaptation is feasible (published
CPGs?)
• TOOL 1: CPG development and adaptation resources
(ADAPTE)
• TOOL 2: (modified) CPG databases on the web, basic list
(Adapted ADAPTE)
Step 2. Establish an organizing committee
Step 3. Select a (high priority CPG topic)
30

31. Phase 1: Set Up (Cont’d)
Step 4. identify necessary resources and skills
Step 5. Complete tasks for the set-up phase
• TOOL 3: Declaration of conflicts of interest form (ADAPTE)
• TOOL 4: Consensus process resources
Step 6. Write adaptation plan
• TOOL 5: Adaptation working plan template (ADAPTE)
• (New) TOOL: Anatomy of the CPG adaptation protocol and
thesis (Adapted ADAPTE)
31

32. Phase 2: Adaptation
2.1. Scope and purpose module
Step 7. Determine the health questions (PIPOH)
• TOOL 6: (modified) PIPOH model tool (Adapted ADAPTE)
2.2. Search and screen module
Step 8. Search for CPGs and other relevant documents
• TOOL 2: search sources and strategies (ADAPTE)
• TOOL 7. Table for summarizing CPG characteristics (ADAPTE)
• (New) TOOL: Checklist for inclusion/ exclusion criteria for
Source CPGs (Adapted ADAPTE)
32

33. Selecting a CPG Topic
 Prevalence of the condition (high volume)
 Patient safety concern (high risk)
 Under-, over-, misuse of intervention(s)
 Burden due to the condition
 Practice variation
 Costs of different practice options
 Likelihood of effectiveness of CPG
 Potential for improving quality of care and/or outcomes
 Existence of relevant good quality CPGs
33

34. 34

35. Health/ Clinical/ Key Questions
Patient (& disease characteristics)
Intervention(s)
Professionals (Target users)
Outcomes (purpose of the CPGs)
Healthcare settings (& context)
CPG Scope: PIPOH Model
35

36. Inclusion / Exclusion CPGs Selection Criteria
(6)
1. Methods of Development: Evidence-Based CPGs: (Detailed
Methodology not Consensus-based CPGs (Expert opinion)
2. Author(s): Organization and Specialized Society not single
authors.
3. Country: International not national CPGs.
4. Date of Publication: range of year of publications: last 5
years or less (e.g. 2011 – 2016) – except if none!
5. Language: English CPGs only
6. Status: only Original source CPG (de novo developed) rather
than adapted CPGs
36

37. Producers Finders
37

38. 1. Governmental (National) organizations: NICE,
SIGN, NHMRC, ,etc.
2. International organizations: WHO.
3. Healthcare Organizations e.g. Best Hospitals
4. Specialized (professional) societies
38

39. 1. CPG Producers: National Organizations
NICE
National Institute
for Health & Clinical
Excellence
www.nice.org.uk

40. 1. CPG Producers: National Organizations
SIGN
Scottish
Intercollegiate
Guidelines
Network
www.sign.ac.uk
14 groups

41. • WHO guidelines for safe surgery: safe surgery
saves lives (2009)
• Best Practice Guidelines on Emergency Surgical
Care in Disaster Situations (2007)
Alexandria Pediatric Center - Scientific Meeting Series 2017 -
Meeting No. (7) 22/8/2017 - Yasser Sami Amer
2. CPG Producers: International Organizations

42. 3. CPG Producers: Healthcare Organizations
CPGs from Best Children’s Hospitals

43. Top 5 in USA for 2017/2018
1. Boston Children's Hospital
2. Children's Hospital of Philadelphia
3. Cincinnati Children's Hospital
Medical Center
4. Texas Children's Hospital, Houston
5. Johns Hopkins Children's Center,
Baltimore
3. CPG Producers: Healthcare Organizations

44. Best
Children’s
Hospitals: UK
NHS Foundation Trust:
1. Great Ormond Street Hospital for Children
2. Birmingham Children's Hospital
3. Sheffield Children’s Hospital
3. CPG Producers: Healthcare Organizations

45. 1. American Academy of Pediatrics
2. Canadian Paediatric Society
3. European Academy of Pediatrics
4. European Society for Pediatric Research
5. …….etc.!
45
4. CPG Producers: Specialized Professional
Societies

46. AAP
4. CPG Producers: Specialized Professional
Societies

47. 4. CPG Producers: Specialized Professional
Societies

48. AHRQ-NGC
National Guideline
Clearinghouse
www.guidelines.gov
> 408 CPGs

49. G-I-N

50. PubMed: US National Library of Medicine,
National Institutes of Health (NIH)
Alexandria Pediatric Center - Scientific Meeting Series 2017 -
Meeting No. (7) 22/8/2017 - Yasser Sami Amer

51. DynaMed
https://dynamed.ebscohost.com/
Alexandria Pediatric Center - Scientific Meeting Series 2017 -
Meeting No. (7) 22/8/2017 - Yasser Sami Amer

52. Organization Name Country URL Producer Finder
Guidelines International Network (G-I-N) International http://www.g-i-n.net F
World Health Organization (WHO) International http://www.who.int/topics P
National Institute for Health & Care Excellence (NICE) UK
http://www.nice.org.uk/page.aspx?o=ourguid
ance
P
Scottish Intercollegiate Guidelines Network (SIGN) UK http://www.sign.ac.uk/guidelines/index.html P
National Guidelines Clearinghouse (NGC), AHRQ USA http://www.guidelines.gov F
EBSCO DynaMed Plus USA dynamed.ebscohost.com/user/login F
US National Library of Medicine, National Institutes of
Health (PubMed)
USA
http://www.ncbi.nlm.nih.gov/pubmed
OR http://www.pubmed.gov
F
Google Scholar USA https://scholar.google.com/?hl=ar&safe=on F
52

53. Phase 2: Adaptation (cont’d)
Step 9. Screen retrieved CPGs
• TOOL 8. Table for summarizing CPG contents (ADAPTE)
Step 10. Reduce large number of retrieved CPGs
• TOOL 9. (modified) AGREE II Instrument or AGREE II-
GRS (Adapted ADAPTE) or only Domain #3 AGREE
• TOOL 10. AGREE Inter-rater Agreement spreadsheet and
AGREE Score calculation spreadsheet (ADAPTE) – replaced by
MY AGREE PLUS Online Tool.
53

54. Phase 2: Adaptation (cont’d)
2.3. Assessment Module
Step 11. Assess CPG quality (the AGREE II Instrument)
TOOLS 9 and 10
Step 12. Assess CPG currency
TOOL 11: currency survey of the CPG developers (ADAPTE)
Step 13. Assess CPG content
TOOL 12: Recommendation Matrix (optional; Adapted ADAPTE)
Step 14. Assess CPG consistency
(TOOLS 13,14: optional; rely on AGREE II domain #3 scores – Adapted
ADAPTE)
54

55. How to assess of the quality of any CPG ?
55

56. 23 Items in 6 Domains
USER’S MANUAL page 7
DOMAINS No. of Items
1 Scope & Purpose 3
2 Stakeholder Involvement 3
3 Rigour of Development 8
4 Clarity & Presentation 4
5 Applicability 3
6 Editorial Independence 2
56

57. The online tool
“My AGREE PLUS”
57

58. AGREE Enterprise website
http://www.agreetrust.org/
58

59. My AGREE PLUS
(OR Our AGREE!)
59

60. My AGREE II Report PDF
60

61. 61

62. Phase 2: Adaptation (cont’d)
2.3. Assessment Module (cont’d)
Step 15. Assess CPG acceptability and applicability
(TOOL 15: optional; rely on AGREE II domain #2 and #5
scores – Adapted ADAPTE)
2.4. Decision and selection module
Step 16. Review assessments
(NEW) TOOL: Decision support table for the overall
adaptation process (Adapted ADAPTE)
62

63. Phase 2: Adaptation (cont’d)
2.4. Decision and selection module (cont’d)
Step 17. Select between CPG recommendations to
create an adapted CPG
2.5. Customization Module
Step 18. Prepare draft adapted CPG
• TOOL 16. (modified) checklist for adapted CPG
contents (Adapted ADAPTE)
63

64. 64

65. Phase 3: Finalization
3.1. External review and acknowledgment
module
Step 19. External review – target audience of the
CPG
•TOOL 17. External review surveys
Step 20. Consult with endorsement bodies
Step 21. Consult of the Source CPG developers
Step 22. Acknowledge source documents65

66. Phase 3: Finalization
3.2. Aftercare planning module
Step 23. Plan for aftercare of the adapted CPG
TOOL 18. table for reporting on results of the update process
3.3. Final Production Module
Step 24. Produce final CPG document
The final CPG includes a section for; ‘Dissemination and
Implementation Considerations: tools and strategies’
(Adapted ADAPTE)
66

67. Implementation
67

68. :: Evidence to practice/ knowledge to action cycle ::
CPG Implementation (CPGI)
Strategies & Tools
68

69. Adapt/ design CPGI Tools
to be made available at the point of care (* MR/ EMR)
Examples
• Clinical Algorithms
• Integrated Care/ Clinical Pathways
• Protocols
• Policies & Procedures
• Chart Documentation/ forms (e.g. Physician Order Sets: paper vs. CPOE
system +/- CDSS)
• Quick Reference Guides/ Physician Guides & Pocket Guide/Reference
Cards (at-a-glance summary of key recommendations).
• Mobile Apps
69

70. • Clinical audit criteria (tool)
• Quality/ Performance measures (process, outcome KPIs)
• Quality Tools (e.g. FMEA)
• Slide Presentation.
• Wall Poster.
• Patient Resources/ Information (HE guides).
• Foreign language Translation (Non-Arabic, Non-French).
• Implementation Tool Kits (collections of tools and/or
strategies).
• Staff Training/ Competency Material.
70
Adapt/ design CPGI Tools (cont.)
to be made available at the point of care (* MR/ EMR)

71. CPG Implementation:
Strategies/ Interventions
1) Leadership engagement and commitment
2) Local Clinical and Quality Champions.
3) Dissemination (print/ e-/web)
4) Education and Training
5) Regular Audit & Feedback (The ‘living’ CPG concept!)
6) Networking and linking with existing projects (e.g. CPD/CME activities,
Accreditation, UG/PG Edu,..etc..).
“Patients as champions for change!”
71