Guideline Development Process

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Clinical practice guidelines for teleoncology > Guideline Development Process

Introduction

The need to develop guidelines for teleoncology was identified as a priority by the Executive of the COSA Regional and Rural Group.The project was approved by COSA Council and a COSA Project Manager assigned. Cancer Council Australia was approached to host the guidelines on the Cancer Guidelines Wiki. No external funding was received to develop these guidelines.

The guidelines were developed by a multidisciplinary working group (see Working Group Members). Question leaders from the working group membership were designated to topics in their areas of expertise, with other working group members contributing as co-authors. The literature assessed for these guidelines focuses on the use of teleoncology throughout the cancer journey.

The guideline development process involved conducting literature searches, appraising the literature, and formulating and grading recommendations is outlined below.

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Working Group Members

COSA would like to thank all the members of the working group who contributed their knowledge, skill and time to the development of these guidelines.

Associate Professor Sabe Sabesan Group Leader
Director, Department of Medical Oncology, Townsville Cancer Centre, QLD and Program Lead, Tropical Centre for Telehealth Practice and Research, Australian Institute of Tropical Health and Medicine, Townsville Hospital, QLD.

Dr Sean Brennan
Radiation Oncologist, Townsville Cancer Centre, QLD

Peggy Briggs
Rural Cancer Nurse Coordinator, WA Country Health Service, WA

Leisa Brown
Nurse Educator, Central Integrated Regional Cancer Service, QLD

Fiona Jonker
General Manager, Medical Services, Icon Cancer Care, QLD

Dr Lisa Mackenzie
Research Associate, Health Behaviour Research Group, University of Newcastle, NSW

Belinda Morris
Lead Cancer Pharmacist, Country Health SA Local Health Network, SA

Professor Ian Olver AM
Director, Sansom Institute of Health Research, University of South Australia, SA

Professor Jane Phillips
Director, Centre for Cardiovascular and Chronic Care, University of Technology Sydney, NSW

Stephen Platt
Cancer Networking Coordinator, WA Cancer & Palliative Care Network, WA

Associate Professor Michael Poulsen
Director, Radiation Oncology Mater Centre, QLD

Dr Christopher Steer
Medical Oncologist, Border Medical Oncology, VIC

Professor Liz Ward
School of Health and Rehabilitation Sciences, The University of Queensland, QLD

Dr David Wyld
Director, Medical Oncology, Royal Brisbane and Women's Hospital, QLD

Dr Rob Zielinski
Medical Oncologist, Central West Cancer Services, NSW

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Conflict of interest register

The following working group members have declared a conflict of interest:

none

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Steps in preparing clinical practice guidelines

Clinical practice guidelines are based on a systematic review where possible. The working group developed clinical questions which determined the scope for the guidelines. The search strategy and literature search was conducted by the Project Manager, who distributed the search results to the working group authors. Authors were assigned to appraise the relevant literature and to formulate evidence-based recommendations where possible. Each author followed a clear strategy in preparing their guideline content.

The steps followed by guidelines authors are outlined below:

  1. Structure the clinical questions
  2. Develop a search strategy
  3. Search the literature
  4. Critically appraise the literature
  5. Formulate and grade recommendations

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Structure the clinical questions

The working group discussed the most important aspects of teleoncology and developed clinically focused questions. These clinical questions were developed and approved by working group members. The clinical questions for the Teleoncology Guidelines are as follows:

What teleoncology models of care are available to health services in Australia and overseas?

What models of care for teleoncology are available to nursing services?

What models of care for teleoncology are available to allied health services?

Is teleoncology as effective as standard oncology care for the screening of cancer?

Is teleoncology as effective as standard oncology care for the diagnosis of cancer?

Is teleoncology as effective as standard oncology care for the treatment of cancer?

Is teleoncology as effective as standard oncology care for the palliative care of cancer patients?

How is the privacy of cancer patients protected when using teleoncology?

Are there any legal issues for health professionals to consider when using teleoncology?

Is teleoncology safe for cancer patients and health professionals compared with standard oncology care?

Are cancer patients and health professionals satisfied with teleoncology compared with standard oncology care?

How cost-effective is it for health services to use teleoncology compared with standard oncology care?

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Develop a search strategy

Appropriate search strategies were constructed for each clinical question. MeSH terms were agreed by working group members and were expanded by the Project Manager after conducting pilot searches and searching the MeSH vocabulary. Where there was no appropriate MeSH index term available a combination of free text words were used in order to capture the relevant data.

The following exclusion criteria was applied: languages other than English. This exclusion criteria was then refined for each individual clinical question. The search strategy was approved by the members of the working group.

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Search the literature

Searches were completed primarily in PubMed. Search results were screened for relevance by the Project Manager. The relevant literature was collated, full-text articles obtained and sent to working group authors to include or exclude, critically appraise and use as the evidence base for their clinical question.

To view more detailed information about the literature search (such as inclusion and exclusion criteria) and the results of the search, please go to each clinical question page. The information can be found in the appendices on each question page.

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Critically appraise the literature

Relevant articles selected from the literature search were reviewed by the clinical question author and each article was critically appraised with respect to level of evidence, quality of the evidence, size of the effect and clinical importance and relevance. Level of evidence was assigned according to the following criteria from the NHMRC Evidence Hierarchy:

Level Intervention Diagnosis Prognosis Aetiology Screening
I A systematic review of level II studies A systematic review of level II studies A systematic review of level II studies A systematic review of level II studies A systematic review of level II studies
II A randomised controlled trial A study of test accuracy with: an independent, blinded comparison with a valid reference standard, among consecutive patients with a defined clinical presentation A prospective cohort study A prospective cohort study A randomised controlled trial
III-1 A pseudo-randomised controlled trial (i.e. alternate allocation or some other method) A study of test accuracy with: an independent, blinded comparison with a valid reference standard, among non-consecutive patients with a defined clinical presentation All or none All or none A pseudo-randomised controlled trial (i.e. alternate allocation or some other method)
III-2 A comparative study with concurrent controls:
  • Non-randomised, experimental trial
  • Cohort study
  • Case-control study
  • Interrupted time series with a control group


A comparison with reference standard that does not meet the criteria required for Level II and III-1 evidence Analysis of prognostic factors among untreated control patients in a randomised controlled trial A retrospective cohort study A comparative study with concurrent controls:
  • Non-randomised, experimental trial
  • Cohort study
  • Case-control study


III-3 A comparative study without concurrent controls:
  • Historical control study
  • Two or more single arm study
  • Interrupted time series without a parallel control group


Diagnostic case-control study A retrospective cohort study A case-control study A comparative study without concurrent controls:
  • Historical control study
  • Two or more single arm study


IV Case series with either post-test or pre-test/post-test outcomes Study of diagnostic yield (no reference standard) Case series, or cohort study of patients at different stages of disease A cross-sectional study Case series

Source: National Health and Medical Research Council. NHMRC levels of evidence and grades for recommendations for developers of guidelines. Canberra: NHMRC; 2009.[1] (https://www.nhmrc.gov.au/_files_nhmrc/file/guidelines/developers/nhmrc_levels_grades_evidence_120423.pdf)

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Formulate and grade recommendations

The body of literature was assessed by each author and recommendation grades were assigned using the following criteria adapted from the NHMRC body of evidence matrix:

Component of Recommendation
Recommendation Grade
A
Excellent
B
Good
C
Satisfactory
D
Poor
Volume of evidence 1** one or more level I studies with a low risk of bias or several level II studies with a low risk of bias one or two level II studies with a low risk of bias or a systematic review/several level III studies with a low risk of bias one or two level III studies with a low risk of bias, or level I or II studies with a moderate risk of bias level IV studies, or level I to III studies/systematic reviews with a high risk of bias
Consistency 2** all studies consistent most studies consistent and inconsistency may be explained some inconsistency reflecting genuine uncertainty around clinical question evidence is inconsistent
Clinical impact very large substantial moderate slight or restricted
Generalisability population/s studied in body of evidence are the same as the target population for the guideline population/s studied in the body of evidence are similar to the target population for the guideline population/s studied in body of evidence differ to target population for guideline but it is clinically sensible to apply this evidence to target population3 population/s studied in body of evidence different to target population and hard to judge whether it is sensible to generalise to target population
Applicability directly applicable to Australian healthcare context applicable to Australian healthcare context with few caveats probably applicable to Australian healthcare context with some caveats not applicable to Australian healthcare context
1 Level of evidence determined from level of evidence criteria
2 If there is only one study, rank this component as ‘not applicable’
3 For example results in adults that are clinically sensible to apply children OR psychosocial outcomes for one cancer that may be applicable to patients with another cancer.
** For a recommendation to be graded A or B, the volume and consistency of evidence must also be graded either A or B!

Source: National Health and Medical Research Council. NHMRC levels of evidence and grades for recommendations for developers of guidelines. Canberra: NHMRC; 2009.[1] (https://www.nhmrc.gov.au/_files_nhmrc/file/guidelines/developers/nhmrc_levels_grades_evidence_120423.pdf)


Recommendation grades are indicated below:

Grade of recommendation
Description
A
Body of evidence can be trusted to guide practice
B
Body of evidence can be trusted to guide practice in most situations
C
Body of evidence provides some support for recommendation(s) but care should be taken in its application
D
Body of evidence is weak and recommendation must be applied with caution
PP
(practice point)
Where no good-quality evidence is available but there is consensus among guideline working group members, consensus-based guidance points are given, these are called "Practice points"

Adapted from: National Health and Medical Research Council. NHMRC levels of evidence and grades for recommendations for developers of guidelines. Canberra: NHMRC; 2009.[1] (https://www.nhmrc.gov.au/_files_nhmrc/file/guidelines/developers/nhmrc_levels_grades_evidence_120423.pdf)

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Write the content

Question authors were asked to write the content for their guideline question using the following format:

  • background
  • review of the evidence
  • evidence summary with levels of evidence and numbered references
  • recommendation(s) and corresponding grade(s)
  • references

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Review of question content

The body of evidence and recommendations for each question topic were reviewed by the working group and final recommendations agreed to, based on the evidence.

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Public consultation

The draft guidelines were released for public consultation to all interested parties in Australia. The consultation process involved soliciting public review of the draft guidelines through posting onto the Cancer Council Australia Cancer Guidelines Wiki and alerting professional societies and other interest groups by link to the site. All feedback on the draft received during the consultation period in Australia was reviewed by the guideline working group. Subsequent changes to the draft was agreed by consensus of the guideline working group, based on consideration of the evidence.

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References

  1. 1.0 1.1 1.2 National Health and Medical Research Council. NHMRC Australian Guidelines to reduce health risks from drinking alcohol. Commonwealth of Australia: National Health and Medical Research Council; 2009 Jan 1 Abstract available at http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/ds10-alcohol.pdf.