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PLOS BLOGS Speaking of Medicine and Health

Why Do We Create Clinical Practice Guidelines?

Guest blogger, Jessie McGowan, ponders why there are so many barriers to using, adapting and implementing clinical practice guidelines.

I have been working on a project of clinical practice guideline (CPG) adaptation with the Canadian Society for International Health in Kazakhstan. However, it became clear that the size of the project was too large for creating de novo CPGs (they requested the development of 100 CPGs in 2.5 years). We decided to be pragmatic and adapt CPGs using ADAPTE and CAN-IMPLEMENT.  I personally, love the philosophy of adaptation because it is evidence-based medicine at its best.  Why reinvent the wheel and use precious resources and duplicate efforts?  If an excellent CPG exists, why not try to tailor it to your local situation?

The solution of adaptation seemed so beautiful and simple. However, as the project progressed it became clear that permission to translate and copyright would become major issues.  The first issue is to translate the CPG into Russian for use by the local Kazakh working groups; the second is to adapt the CPG into the Kazakh context and to produce a new adapted CPG for dissemination and implementation in Kazakhstan.

As I worked with publishers and guideline producers, I found that there is no one process to receive permission to translate.  It is time consuming (up to 5 months and many emails) and sometimes there are fees.  Frequently, when I tried to request permission through a third party, the option for translation wasn’t available and I have had to personally contact the publisher.

Old and new in Astana, Kazakhstan. Image Credit: Jessie McGowan

When I have requested permission to “adapt” I found that most publishers and producers did not know how to deal with the request. Technically, one can view adaptation as an academic activity.  If this is so, then, I believe, as long as you follow correct citation rules, you should be okay.  However, if large parts of the CPG are being reprinted, then it is necessary to seek permission.  However, what does “large parts of content” mean and how does “fair dealing” work in Kazakhstan?  ADAPTE and CAN-IMPLEMENT both recommend consulting with the source developers, but actual process guidance is not included (and I can certainly understand why).

One silver lining is with open access. Articles published under an open-access license are not only free to read, but all reuse is permitted provided only that the original article is properly cited. However, the vast majority of CPGs I have been dealing with are not available through an open-access license.

After all of this, I find myself going back to some basic questions.  Why do we produce CPGs?  How do CPG producers expect the CPG to be used or implemented?

If CPGs are important tools for clinical decision makers to make the best decision for their patients, then why are there so many barriers to the use, adaptation and implementation?

Should there be an effort to raise the awareness of the importance of using CPGs? Should journal publishers and CPG producers try to create policies to ensure that the CPGs can be used broadly? Should CPG producers be encouraged to publish in open-access publications?  Leave me a comment a let me know what you think!

Jessie McGowan has a PhD in information science and is a library and health consultant from Toronto, Canada.  She also holds adjunct faculty appointments in medicine and family medicine from the University of Ottawa.  Contact:

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