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Global Guidelines and Regional Implementation
Rowan G. Walker

CARI (Caring for Australasian with Renal Impairment) 1 represents one region of the world (Australasia) where clinical practice is (or should be) relatively uniform. Thus opportunities exist to develop clinical practice guideline implementation strategies that are likely to have applicability across many centres caring for patients with Chronic Kidney Disease throughout the region. CARI has also historically placed great importance on implementation - for this reason the 'model CARI guideline' has always included 'implementation' as part of it and all new guideline writers are encouraged to offer written, meaningful implementation strategies as an essential element of their guidelines.

Likewise, KDIGO2 as custodians of the global guideline development have placed great importance on implementation - there are two separate work groups looking at implementation; one whose energy is directed at areas of the world where clinical practice guidelines in their written form are already established and another to look at areas of the world where formal guidelines do not exist but where implementation of global guidelines or other clinical practice guidelines could be considered.

Implementation is the most difficult challenge of all the rudiments of clinical practice guidelines. Overcoming barriers to implementation and thus changing practice is clearly critical to the fulfilment of the aims of improving patient outcomes. In considering implementation projects, CARI has developed some very basic aspirations and some selection criteria - the list is not exhaustive.

What are the fundamental desired outcomes?

  • Changed knowledge
  • Changed Practice
  • Changed Patient Outcomes

What might be useful Criteria for Choosing a Guideline for Implementation?

  • Concern about a particular clinical problem
  • Concern about a clinical problem which has potentially serious outcome(s)
  • Concern about a reasonably common clinical problem
  • Concern about an area in which clinical practice is known to be variable
  • Do the Guideline and the practice have outcomes that are measurable?
  • Concern that an area is chosen for which good quality evidence is available to guide decision making
  • Have a reasonable cost for implementation
  • Have a reasonable likelihood of successful implementation after consideration of cost, practicality etc.


The implementation of clinical practice guidelines at a global, regional level or even a local level will not happen by chance - it requires funding, resources, commitment and endeavour. Thus, one strategy adopted at CARI is to seek specific funding opportunities directed solely at implementation. One such project was to examine the achievement of iron targets3 in dialysis dependent patients and another recently undertaken project is the timeliness of establishment of vascular access for dialysis.

Implementing regionally-based Clinical Practice Guidelines in a regional setting is a challenge in itself. Implementation of Global Guidelines in a regional setting is a challenge of a substantially greater magnitude. The evidence-base may be identical as is the need to improve the outcome for patients but the environment, the culture, the resources and the scale of the problem may be so different that it demands the need for Global Guideline writers and implementers to consider that many different implementation strategies may be required to achieve the goals. Strategies need to be applied differently not only between regions of the world but the application may need to be quite different even between individual institutions within that region.

The need to reaffirm the common goal of aiming to improve patient outcomes is paramount as is the need to adequately resource implementation strategies.

 

1. The CARI Guidelines. www.cari.org.au/index.php
2. KDIGO: www.kdigo.org/
3. Irving,M.J.; Craig,J.C.; Gallagher,M.; McDonald,S.; Polkinghorne,K.R.; Walker,R.G.; Roger,S.D. Implementing iron management clinical practice guidelines in patients with chronic kidney disease having dialysis. Med J Aust.185(6): 310-314