Commentary on “The advantages and limitations of guideline adaptation frameworks.”
The tension between fidelity and fit when implementing evidence-based interventions or clinical guidelines has been an ongoing debate in Implementation Science. While it is widely recognized that some adaptation to fit interventions to local contexts is necessary, there are no hard and fast rules on how much adaptation is too much, or how much is too little to encourage local uptake. Some of this uncertainty is inevitable because adaptation itself is context dependent and there is no single formula to determine the right type and amount of adaptation suitable for diverse contexts. But overall, the research on different methods or levels of adaptation and their effect on outcomes is still limited.
However, as in many areas in Implementation Science, frameworks to assist in the adaptation process have proliferated. The featured paper by Wang and colleagues is a scoping review of eight frameworks to support the adaptation of clinical guidelines.1 The authors provide a timeline of when various frameworks were developed from 2005 to 2017, and describe how the focus of the frameworks has shifted in the past decade. The earlier frameworks focused on the selection of an appropriate guideline to adapt. Later frameworks have advocated selecting a single well-known guideline, and adapting the recommendations made within that guideline. Some of the most recent guidelines (e.g., GRADE-ADOLOPMENT from 2017) go a step further, integrating new evidence synthesis into the adaptation process to create new recommendations if necessary.
As the adaptation frameworks become more flexible and sophisticated, the authors contend that they have significant limitations that impede their effective utilization. As they become more complex, and recommend acquisition and evaluation of new evidence, they are also more time consuming and resource intensive, and require greater expertise in critical evidence appraisal. This makes them unsuitable for low resource settings, and indeed, most of the frameworks to date have been tested only in upper-middle and high-income countries. Moreover, there is little evidence about the effectiveness of the frameworks, since most evaluations focus only on usability of the frameworks. There are no criteria for decision making about adaptation other than consensus among the expert committees. Finally, there is little guidance on how to implement adapted guidelines.
These findings align with those from an earlier scoping review of adaptation frameworks for implementing evidence-based public health interventions conducted by Escoffery and colleagues.2 This study compared 13 adaptation frameworks developed for public health interventions. Interestingly, none of these frameworks overlapped with the eight identified by Wang and colleagues, reflecting the degree of fragmentation that still exists in the field. However, some of the findings from this review parallel those in the article by Wang et al. There were few frameworks from settings outside the United States. While implementation was identified as a need and included in several frameworks, few of them addressed changes to implementation protocols or training of implementers. Unlike in the frameworks for adapting clinical guidelines, consultation with experts was not often mentioned in the public health frameworks. The hypothesized reason is that this could be time consuming and resource intensive, which was also mentioned by Wang et al. Finally, evaluation of the effectiveness of these frameworks in particular, and of adaptation processes in general, remains necessary.
Much of the research in Implementation Science remains conceptual and theoretical, perhaps due to difficulties in testing complex interventions in complex field settings. Frameworks, whether they be for testing adaptations or for guiding implementation are useful, but in the long run have limited utility to provide guidance to practitioners unless they are empirically tested. While the same experimental standards for clinical guidelines may not be feasible for implementation guidelines, rigorous iterative approaches using methods such as PDSA cycles, innovative qualitative methods and systematic documentation of implementation and adaption is necessary to go beyond reviews of frameworks to their evaluation. Both scoping reviews mention this as areas for future research.
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1Wang, Z., Norris, S. L., & Bero, L. (2018). The advantages and limitations of guideline adaptation frameworks. Implement Sci, 13(1), 72. doi:10.1186/s13012-018-0763-4
2C. Escoffery, E. Lebow-Skelley, H. Udelson, E. A. Boing, R. Wood, M. E. Fernandez and P. D. Mullen. (2018). A scoping study of frameworks for adapting public health evidence-based interventions. Transl Behav Med.