Reumatología Clínica

Reumatología Clínica

Volume 10, Issue 6, November–December 2014, Pages 364-372
Reumatología Clínica

Original article
Barriers to implementing the “2008 Mexican Clinical Practice Guideline recommendations for the management of hip and knee osteoarthritis” in primary healthcare practiceBarreras para la implementación de la «Guía Mexicana de Práctica Clínica para el manejo de osteoartritis de cadera y rodilla en el primer nivel de atención 2008» en la práctica de atención primaria

https://doi.org/10.1016/j.reuma.2014.01.010Get rights and content

Abstract

Objective

To evaluate the implementability of the “2008 Mexican Clinical Practice Guideline for the management of hip and knee osteoarthritis at the primary level of care” within primary healthcare of three Mexican regions using the Guideline Implementability Appraisal methodology version 2 (GLIA.v2).

Methods

Six family physicians, representing the South, North, and Central Mexico, and one Mexican physiatrist evaluated the 45 recommendations stated by the Mexican guideline. The GLIA.v2 methodology includes the execution of qualitative and semi-quantitative techniques.

Results

Reviewers’ agreement was between moderate to near complete in most cases. Sixty-nine percent of the recommendations were considered difficult to implement within clinical practice. Eight recommendations did not have an appropriate format. Only 6 recommendations were judged as able to be consistently applied to clinical practice. Barriers related to the context of one or more institutions/regions were identified in 25 recommendations. These barriers are related to health providers/patients’ beliefs, processes of care within each institution, and availability of some treatments recommended by the guideline.

Conclusions

The guideline presented problems of conciseness and clarity that negatively affect its application within the Mexican primary healthcare context. We identified individual, organizational and system characteristics, which are common to the 3 institutions/regions studied and constitute barriers for implementing the guideline to clinical practice. It is recommended that the 2008-Mexican-CPG-OA be thoroughly revised and restructured to improve the clarity of the actions implied by each recommendation. We propose some strategies to accomplish this and to overcome some of the identified regional/institutional barriers.

Resumen

Objetivo

Evaluar las barreras de implementación de la guía de práctica clínica para el manejo de osteoartritis de cadera y rodilla en el primer nivel de atención 2008 dentro de la práctica clínica de 3 regiones mexicanas, usando la metodología Guideline Implementability Appraisal version 2 (GLIA v2).

Métodos

Seis médicos familiares, representantes del sur, norte y centro de México, y un médico rehabilitador mexicano evaluaron las 45 recomendaciones propuestas en la guía de práctica clínica. La metodología GLIA v2 incluye la ejecución de técnicas cualitativas y semicuantitativas.

Resultados

En su mayoría, el acuerdo entre revisores fue de moderado a casi completo. El 69% de las recomendaciones fueron consideradas como difíciles de implementar en la práctica clínica. Ocho recomendaciones no tienen un formato apropiado. Únicamente 6 recomendaciones pueden ser aplicadas consistentemente en la práctica clínica. En 25 recomendaciones, se detectaron barreras de implementación relacionadas al contexto de una o más de las instituciones/regiones exploradas. Estas barreras se relacionan con las creencias de proveedores de salud y pacientes, procesos de atención en cada institución y disponibilidad de algunos de los tratamientos recomendados en la guía.

Conclusiones

La guía contiene recomendaciones poco claras y concisas, lo que afecta negativamente a su aplicación dentro del primer nivel de atención mexicano. Identificamos características individuales, organizacionales y sistemáticas, comunes a las 3 instituciones/organizaciones estudiadas, que significan barreras para implementar la guía en México. Se recomienda que esta guía sea revisada y reestructurada con el fin de mejorar la claridad de sus recomendaciones. Proponemos algunas estrategias para hacer esto y atacar algunas de las barreras identificadas relacionadas dentro de las regiones exploradas.

Introduction

Osteoarthritis (OA) is a chronic musculoskeletal disease of the joints that has a negative impact on the healthy aging of the population.1 This chronic condition produces disability resulting in significant costs to the society.2 It is estimated that in Mexico 10.5% of the people with musculoskeletal pain have OA,3 the knee being the most commonly affected joint.4, 5, 6 The high prevalence of OA within the Mexican population produces a high demand for healthcare, representing one of the 10 most common problems seen at the primary level of care in the Mexican Institute of Social Security (IMSS), one of the main public health institutions of the country.7

In Mexico, people with OA are usually managed by general and family physicians within the primary healthcare system,4 representing one of the principal sources of cost for this level of care.8 Consequently, there is an interest in containing the high social and economic costs produced by this chronic disease through development and implementation of clinical practice guidelines (CPG) that standardize management across the country.9 Clinical practice guidelines are systematically developed statements or recommendations that assist in the decision-making process within healthcare.10 In 2008, the Mexican Secretary of Health coordinated the development of a CPG for the management of knee and hip OA at the primary level of care with the main purpose of providing evidence-based recommendations to decrease the disabling effects of hip and knee OA in the Mexican population.11 The developers of this guideline used existing CPGs from other countries to structure their recommendations for practice.9

The CPGs used to create the “2008 Mexican Clinical Practice Guideline for the management of knee and hip OA at the primary level of care (2008-Mexican-CPG-OA)” have not been fully implemented within their own contexts.12, 13, 14, 15 This situation raises questions about the direct transferability of the recommendations stated by the 2008-Mexican-CPG-OA to the Mexican context. According to the Knowledge-To-Action (KTA) framework, in order to successfully apply a knowledge tool such as a CPG, it is important to identify potential barriers to its implementation, considering the local context in which it will be utilized.16

The implementability of a CPG refers to a set of its recommendations’ characteristics that permit their successful conversion into actions.17 Only clear, concise, and actionable recommendations can be successfully implemented in clinical practice.18, 19 In consequence, it is possible to assess the barriers to implementation of a CPG through analyzing the characteristics of its recommendations.

The Mexican Public Health system is formed by different institutions, such as the IMSS and the Secretary of Health (SS), each with its own government structures and procedural mechanisms. Even within each institution there are region-related structural and systemic differences. This situation underlies the complexity of the public Mexican Healthcare system, implying the presence of different healthcare contexts that could affect the implementability of the 2008-Mexican-CPG-OA.

As a result, the idea behind this study was to use the concept of “CPG implementability” to evaluate the recommendations proposed in the 2008-Mexican-CPG-OA. The main objectives were to evaluate the implementability of the 2008-Mexican-CPG-OA within different Mexican Healthcare institutions at the primary level of care in three Mexican regions (Northern, Central, and Southern) and to put forward some strategies to improve its successful implementation within clinical practice in Mexico. To accomplish this, we used the GLIA v2 instrument to: (a) identify implementation barriers for each recommendation of the guideline, (b) disclose differences on implementability issues among each institution and region, and (c) propose strategies to address the identified barriers.

Section snippets

Design overview

This was a consensus-based exercise that used qualitative and semi-quantitative techniques, following the methodology proposed by the Yale Center for Medical Informatics known as the Guideline Implementability Appraisal version 2 (GLIA v2).17 Six family physicians and one physiatrist collaborated to evaluate the barriers for the implementation of the recommendations stated by the 2008-Mexican-CPG-OA within their clinical practices.

Reviewers

The family physicians formed three teams representing different

Results

The reviewers had been practicing family medicine for an average of 17 years (min – 7, max – 27) and dedicate 5–30% of their weekly clinical time to the management of OA. All reviewers were familiar with evidence-based practice concepts, and 4 reviewers were undertaking postgraduate studies in health research methodology. Two reviewers were aware of the existence of the 2008-Mexican-OA-CPG before starting this project; none of them had received training for implementing this guideline. Only one

Discussion

This study uncovered some aspects of the 2008-Mexican-CPG-OA that can impede its successful implementation within the IMSS-Estado de México, Quintana-Roo and Yucatán, and in the SS-Morelos and Nuevo León. As a whole, the guideline presented problems of conciseness and clarity that negatively affect its credibility and application within the Mexican primary healthcare context. Only 6 of the 45 recommendations (14%) were considered to be implementable in a consistent way. We also detected

Protection of human and animal subjects

The authors declare that no experiments were performed on humans or animals for this investigation.

Confidentiality of data

The authors declare that no patient data appear in this article.

Right to privacy and informed consent

The authors declare that no patient data appear in this article.

Conflicts of interest

All authors declare no conflicts of interest.

Acknowledgements

We thank Dr. Thelma Martinez Villareal, Dr. Mario Garza and Dr. Jorge Esquivel Valerio from the research department of the School of Medicine at the Universidad Autónoma de Nuevo León for their invaluable input and support during the conduction of this study. Adalberto Loyola-Sanchez is a recipient of a CONACYT (Consejo Nacional de Ciencia y Tecnología) scholarship for foreign studies and a CIHR (Canadian Institute for Health Research) Vanier scholarship. Travel expenses were partially covered

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