Original articleBarriers 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
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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