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T
he knowledge-to-action cycle represents a frame-
work for the implementation of knowledge.
1
As dis-
cussed in the first article in this series, the action
phases of this cycle were derived from a review of 31 theo-
ries of planned action.
2
Included in this cycle (Figure 1) are
the processes needed to implement knowledge in health care
settings. In this paper, we address the adaptation of the
knowledge to the local context and assessment of barriers to
and facilitators of the use of knowledge. The action cycle is
a dynamic and iterative process with each phase informing
the others.
Why adapt guidelines for local use?
Using the best evidence is a fundamental aspect of quality
health care and valid guidelines for clinical practice are an
important tool to inform evidence-based practices. Guidelines
are derived from synthesized evidence that has been trans-
lated into specific practice-oriented recommendations.
3
The
production of guidelines has been promoted and supported by
governments and professional organizations as a mechanism
for reducing variations in practice. Many countries have infra-
structure at the national or regional level dedicated to synthe-
sizing evidence and producing guidelines, as well as incen-
tives designed to support practices guided by current
recommendations of guidelines.
4
The goals of these initiatives differ depending on the polit-
ical context and the health care system. For instance, in the
United Kingdom, the National Health Service has infrastruc-
ture and incentives to deliver care guided by recommenda-
tions of guidelines. National bodies such as the National Insti-
tute for Health and Clinical Excellence
5
are dedicated to
synthesizing evidence and producing guidelines for use
within the National Health Service. To assess the uptake and
adherence to guideline-based care, auditing functions exist
across trusts (i.e., regions) in the National Health Service.
Despite these efforts, evaluation of these strategies for imple-
mentation show that overall conformity of practices lags
behind expectations.
6
Although high-quality guidelines may be seen as necessary,
they are not sufficient to ensure evidence-based decision-
making. Uptake of knowledge does not occur with simple dis-
semination and usually requires a substantive, proactive effort
to encourage use at the point of decision-making.
7
The gap
between valid recommendations of guidelines and delivery of
care based on this evidence may be due to numerous barriers.
For instance, clinicians may not have the requisite skills and
expertise to implement a recommended action (e.g., being
unfamiliar with how to initiate or titrate a new medication), or
the setting may not have the mandatory equipment or its staff
the time to deliver a guideline’s recommendation.
3
Although guidelines provide evidence in a more usable
form for clinicians than a plethora of primary studies, an
important and additional necessary step is the adaptation of
the guideline to the local context of use. National and interna-
tional bodies have made major efforts to improve the quality
and rigour of guidelines,
8,9
but less investment has been made
in understanding how guidelines can be targeted to the local
context of health care. By local, we mean a continuum of con-
texts that could range from a single clinic to a hospital, region
or nation.
Customizing a clinical practice guideline to a particular
organization may improve acceptance and adherence. Active
involvement of the end-users of the guideline in this process
has been shown to lead to significant changes in practice.
10–13
For example, local and regional adaptations of international
DOI:10.1503/cmaj.081232
Adapting clinical practice guidelines to local context and
assessing barriers to their use
Margaret B. Harrison RN PhD, France Légaré MD PhD, Ian D. Graham PhD, Béatrice Fervers MD PhD
From the School of Nursing, the Department of Community Health and Epi-
demiology and the Practice and Research in Nursing Group (Harrison),
Queen’s University, Kingston, Ont.; the Department of Family Medicine and
Emergency Medicine, Université Laval, and Centre de Recherche du Centre
Hospitalier Universitaire de Québec (Légaré), Québec, Que.; the Canadian
Institutes of Health Research and the School of Nursing (Graham), Depart-
ment of Epidemiology and Community Medicine, University of Ottawa,
Ottawa, Ont.; and the Oncology Guideline Programme (Fervers), French
Federation of Cancer Centers, Centre Léon-Bérard and Université Lyon,
Lyon, France.
Cite as CMAJ 2009.DOI:10.1503/cmaj.081232
Key points
• Clinical practice guidelines can be adapted to local
circumstances and settings to avoid duplication of efforts
and optimize use of resources.
• The ADAPTE process is an approach to adapting guidelines
to local contexts through the explicit participation of
relevant decision-makers.
• Assessing barriers to and facilitators of the use of
knowledge is closely linked to the adaptation and uptake
of the evidence.
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CMAJ • FEBRUARY 9, 2010 • 182(2)
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evidence-based practice guidelines have become mandatory
for the care of patients with cancer in France.
14
For many
regions and territorial jurisdictions, de novo development of
guidelines is not feasible because of lack of time, expertise
and resources, and thus taking advantage of existing high-
quality guidelines is sensible.
15–17
Adaptation of existing high-quality guidelines for local use is
an approach with the potential to reduce duplication of effort
and enhance applicability. National guidelines often lack details
on applicability and description of the changes in the organiza-
tion of care required to apply the recommendations.
18
Adapta-
tion of evidence may promote local uptake of evidence through
a sense of ownership by the end-users who are engaged in this
process. However, customizing a guideline to local conditions
could weaken the integrity of the evidence base. We outline a
systematic, participatory approach for evaluating and adapting
available guidelines to a local context of use while maintaining
the quality and validity of the guideline. Whether evidence is
provided in the format of syntheses of knowledge, patient deci-
sion aids or clinical practice guidelines, end-users must consider
if or how it could be adapted to the local context and the same
principles can be applied to ensure these factors are considered
before implementation of the evidence.
To illustrate how to adapt guidelines, we will use a recent
study that was performed to improve community care of indi-
viduals living with venous ulcers of the leg.
10,13
Regional man-
agers of home care were concerned about costs of supplies,
amount of nursing time, and frequency of visiting for clients
with ulcers of the leg. A regional task force was developed to
review existing practice guidelines to help guide the care
plan. The task force identified that many of these guidelines
were from international bodies and would require adaptation
to the local context.
How are guidelines adapted for local use?
Existing guidelines can be evaluated and customized to fit
local circumstances through an active, systematic and partici-
patory process. This process must preserve the integrity of the
evidence-based recommendations when differences in organi-
zational, regional or cultural circumstances may legitimately
require important variations in recommendations.
8,9,14–16,19
In
adapting a guideline, consideration is given to local evidence,
such as specific health questions relevant to a local context of
use; to specific needs, priorities, legislation, policies and
resources; to scopes of practice within the local health ser-
vices; and to fit within existing models of delivery in the tar-
geted setting. Adapting the guideline to this local evidence is
assumed to improve uptake of the guidelines.
Returning to our example involving care of ulcers of the
leg, the task force collectively assessed the quality of individ-
ual guidelines and their recommendations. They developed a
protocol that was feasible to implement locally and that was
endorsed by stakeholders. The guideline was condensed to a
one-page algorithm to enhance use by the
clinicians, and documentation forms were
created for collection of clinical data. For
example, to streamline the process of
assessment and facilitate application of
evidence-based care, documentation forms
were created to collect information about
the cause of the ulcer, with venous symp-
toms and history on one side of the page
and arterial symptoms on the other.
With the exception of a few studies
such as this collaboration for care of ulcers
of the leg,
10,13,17
no validated process for the
adaptation of guidelines has been docu-
mented. Recently, the Canadian work
16
in
this area was integrated with an interna-
tional initiative known as the ADAPTE
collaboration (www.adapte.org).
19
This col-
laboration is a group of researchers and
developers, implementers and users of
guidelines whose aim is to enhance the use
of research-based evidence through more
efficient development and implementation
of practice guidelines. The ADAPTE
process was developed to facilitate the cre-
ation of efficient, high-quality adapted
guidelines. The process engages end-users
in the guideline adaptation process to
address specific health-related questions
relevant to its context of use. The goal is to
establish a standard of being transparent,
Monitor
knowledge
use
Evaluate
outcomes
Sustain
knowledge
use
Adapt
knowledge to
local context
Select, tailor,
implement
interventions
Assess barriers
to knowledge
use
Identify problem
KNOWLEDGE CREATION
Knowledge
inquiry
Synthesis
Products/
tools
Tailoring knowledge
Identify, review,
select knowledge
ACTION CYCLE
(Application)
Figure 1: The knowledge-to-action cycle.
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CMAJ • FEBRUARY 9, 2010 • 182(2)
E80
rigorous and replicable based on the following core principles:
• Respect of evidence-based principles in the development
of guidelines,
20
• Use of reliable and consistent methods to ensure the qual-
ity of the adapted guideline,
9,19
• Participation of key stakeholders to foster acceptance and
ownership of the adapted guideline and ultimately promote
its use,
13,14
• Consideration of context during adaptation to ensure rele-
vance for local practice and policy,
13,21
• Transparent reporting to promote confidence in the recom-
mendations of the adapted guideline,
9,20
• Use of a flexible format to accommodate specific needs
and circumstances,
18,22
and
• Respect for and acknowledgement of guideline materials
used as sources.
What is the ADAPTE process?
The ADAPTE process consists of three main phases, includ-
ing planning and set-up, adaptation, and development of a
final product (Box 1). The set-up phase outlines the necessary
tasks to be completed before the process of adaptation, includ-
ing identifying necessary skills and resources, and designing
the panel. The panel should include relevant end-users of the
guideline, such as clinicians, managers and patients.
The phase of adaptation assists in moving from selection
of a topic to identification of specific clinical questions; in
searching for, retrieving and assessing guidelines; in decision-
making around adaptation; and in preparing the draft version
of the adapted guideline. Assessment of the retrieved guide-
lines involves evaluation of their quality (i.e., using the
AGREE [Appraisal of Guidelines Research and Evaluation]
instrument
9,23
), currency (i.e., how up-to-date they are) and
consistency (i.e., congruence of the recommendation with the
underlying evidence). Assessment also consists of the exami-
nation of the acceptability (i.e., to clinicians and patients) and
applicability (i.e., feasibility of applying recommendations) of
the guidelines’ recommendations within the proposed context
of use. This evaluation provides an explicit basis for informed
and transparent decision-making around the selection and
modification of guidelines used as sources. This process can
result in different alternatives ranging from adopting a guide-
line unchanged, to translation of language and adaptation of
format, to modification and updating of single recommenda-
tions, to the production of a customized guideline based on
various guidelines used as sources. The finalization phase
includes external review, feedback from relevant stakehold-
ers, and consultation with the developers of source guidelines.
Establishing a process for updating the adapted guideline and
writing the final document are the last stages.
The ADAPTE process is supported by tools on the
ADAPTE website, including a manual and toolkit. For each
module, the manual provides a detailed description of the aims
and tasks, the products and deliverables, and the skills and
organizational requirements necessary to undertake the tasks.
An example related to the adaptation of guidelines for screen-
ing for cervical cancer is provided throughout the modules. In
the toolkit, 19 tools or instruments are offered to help structure
the process and collect necessary information for decision-
making.
For example, tool number 2 offers a comprehensive search
strategy to help in identifying existing guidelines by searching
websites of sources of guidelines (e.g., guideline-related clearing-
houses, known developers’ sites, specialty organizations) and
MEDLINE. Tool number 6 helps a group convert the topic of the
guideline into a set of clear and focused key questions before the
process of adaptation. Tool number 15 proposes a series of struc-
tured questions and criteria to guide the assessment of and dis-
cussion on whether a recommendation of a guideline is applica-
ble or acceptable in the planned context of use and to identify the
organizational changes that may be needed to deliver the recom-
mendation. Steps and tools are flexible and have been designed
to allow for alteration in the sequence in which they are used to
fit with users’ time or restraints in resources.
Adapting a guideline or other tool of knowledge is a key
component of the knowledge-to-action cycle. The adaptation
process also integrates other steps of the cycle, including assess-
ment of barriers to and facilitators of use of knowledge, which is
necessary both for adapting and implementing the guideline.
Key concepts for assessment
The use of a framework is important for assessing barriers
because it helps researchers and practitioners identify
research questions, generate testable hypotheses, assess out-
comes using valid and reliable instruments and make valid
inferences from their results. A framework would ensure that
researchers can elaborate theory-based interventions that have
the potential for increasingly effective implementation of
knowledge into clinical practice.
24
More importantly, the use
of a framework also provides the foundation for the tools that
help busy clinicians implement practice guidelines.
One of the more often-cited conceptual frameworks regard-
ing barriers to use of knowledge in health care is the Clinical
Practice Guidelines Framework for Improvement by Cabana
and colleagues.
25
This framework was based on an extensive
search of the literature for barriers to adherence by physicians
to clinical practice guidelines and was organized according to
knowledge, attitudes and behaviour of physicians.
26
Of 5658
potentially eligible articles, Cabana and colleagues identified
76 published studies describing at least one barrier to adher-
ence to clinical practice guidelines. The included articles
reported on a total of 293 potential barriers to adherence to
guidelines by physicians. These barriers included unawareness
of the existence of the guideline (n = 46), unfamiliarity with
the recommendations of guidelines (n = 31), disagreement
with the recommendations (n = 33), lack of self-efficacy (i.e.,
feeling one is unable to carry out the recommendations)
(n = 19), outcome expectancy (i.e., the perception that health
outcomes will be changed if the recommendations are fol-
lowed) (n = 8), inability to overcome the inertia of previous
practice (n = 14) and presence of external barriers to following
the recommendations (n = 34).
25
Espeland and Baerheim
27
proposed a revised and extended
classification of barriers based on the Clinical Practice Guide-
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CMAJ • FEBRUARY 9, 2010 • 182(2)
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Box 1: Phases, modules and steps in the adaptation of a guideline using the ADAPTE process.
A scenario of care of patients with leg ulcers is included as an example. (Part 1 of 2)
PHASE I — Set-up
Module: Preparation
1. Establish an organizing committee, working panel or resource team.
This group will determine the scope of the project, terms of reference and a working plan.
(Example: A regional task force was formed that comprised home care nurses, family physicians and
specialists involved in the care of patients with leg ulcers [i.e., hematologist, dermatologist]).
2. Determine criteria for selection and select a topic using criteria.
Criteria can include prevalence of disease; evidence of underuse, overuse or misuse of
interventions and existence of an evidence-based guideline. (Example: A review was performed
of the extent of community-based care of chronic wounds. The most prevalent type of wound
was identified as venous leg ulcer. The existence of high-level evidence for management was
confirmed.)
3. Check if adaptation is feasible.
Determine if a guideline is available. (Example: A systematic search was performed. Numerous
high-quality guidelines available from credible agencies [RCN, SIGN, RNAO] were identified.)
4. Identify necessary resources and skills.
Resources to consider include a high level of commitment by members of the panel, funds to cover
costs of meetings, and qualified people to manage the project. Necessary skills include expertise in
content, critical appraisal, retrieval of information, implementation and policy. (Example: A need for
input from family physicians, nurses and specialists was identified. Methodological support for the
panel by local researchers was negotiated.)
5. Complete tasks of the set-up phase.
Tasks include development of terms of reference, declaration of competing interests and process for
consensus, identification of endorsement bodies, determination of authorship of the guideline and
development of strategies for dissemination and implementation. (Example: Members of the group
decided to function as a working group and share authorship, providing reports to the home care
authority and nursing agencies involved.)
6. Write the plan for adaptation.
The plan may include details of the topic, membership of the panel, declaration of competing
interests and a proposed timeline. (Example: A plan and a timeline for completion were agreed upon
by the working group.)
PHASE II — Adaptation
Module: Scope and purpose
7. Determine and clarify the health-related question.
Focus on the Population of interest, the Intervention of interest, the Professions to which the
guideline is to be targeted and the Outcomes and Health care setting of interest (PIPOH).
(Example: Using the PIPOH approach, the group decided that the population of interest was people
with venous leg ulcers; the interventions of interest were assessment and management of these
patients; the professions targeted were community nurses; the outcome of interest was healed ulcers;
and the health care setting was the community.)
Module: Search and screen
8. Search for guidelines and other relevant documentation.
Search for relevant guidelines, systematic reviews and reviews of health-related technology that have been
published since the guideline. (Example: The group of researchers searched for relevant guidelines.)
9. Screen the retrieved guidelines and record their characteristics and content.
Perform a preliminary screening to determine if the guidelines retrieved are relevant to the topic.
(Example: The working group identified 8 relevant guidelines.)
10. Eliminate a large number of the retrieved guidelines using the AGREE instrument.
Use the rigour dimension of the AGREE tool to assess the quality of the guideline. Include for further
assessment only those that are of highest quality.
Module: Assess guidelines
11. Assess the quality of the guideline.
Use the AGREE instrument to assess quality. We suggest that 2 to 4 members do this step
independently.
12. Assess the currency of the guideline.
Review the search and dates of publication of the guideline to ascertain inclusion of the most
current evidence. This step requires input from an information scientist and content experts.
(Example: Four guidelines for management of leg ulcers were eliminated after assessment of
rigour and currency.)
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Box 1: Phases, modules and steps in the adaptation of a guideline using the ADAPTE process.
A scenario of care of patients with leg ulcers is included as an example. (Part 2 of 2)
13. Assess the content of the guideline.
Content can be considered in either of 2 formats: recommendations provided and grouped by
guideline or recommendations grouped by similarity (e.g. topic covered). (Example: Assessment of a
leg wound was compared and in all of the high-quality guidelines, an ABPI was taken along with a
detailed clinical assessment.)
14. Assess the consistency of the guideline.
Assess the search strategy and selection of evidence supporting the recommendations, the
consistency between selected evidence and how developers summarize and interpret the evidence,
and the consistency between the interpretation of the evidence and the recommendations.
(Example: The ABPI was supported with high-level evidence in 4 guidelines.)
15. Assess the acceptability and applicability of the recommendations.
Module: Decision and selection
16. Review assessments.
Provide the panel with all documents summarizing the review, including the AGREE results and
recommendations. (Example: The AGREE scores were displayed on bar graphs to easily differentiate
quality scores. The recommendations for assessment and management were synthesized on a matrix
of recommendations including the levels of evidence.)
17. Select among guidelines and recommendations to create an adapted guideline.
Consider the following options: reject the whole guideline; accept the whole guideline, including
summary of evidence and recommendations; accept the summary of evidence; accept specific
recommendations; modify specific recommendations. (Example: One main guideline was used
because the recommendations compared well with the other high-quality guidelines and the
practice-based recommendations were well-stated.)
Module: Customization
18. Prepare a draft of the adapted guideline.
Prepare a draft document respecting the needs of the end-users and providing a detailed
explanation of the process used to derive the recommendations. (Example: The co-chair of the
working group compiled the results of the deliberations and wrote the local protocol.)
PHASE III — Finalization
Module: External review and acknowledgement
19. Seek feedback on the draft adapted guideline from those who would be using it.
Include targeted users of the guideline, such as clinicians, managers and policy-makers. Ask whether
they agree with recommendations, whether gaps exist, whether the guideline is acceptable and
whether it has any resource-related implic ations. (Example: A copy was circulated for comment to all
family physicians and home care nurses in the region.)
20. Consult with endorsement bodies.
Engage relevant professional organizations and societies to endorse the guidelines. (Example: Home
care authority and nursing agencies endorsed the protocol as “usual care” for referrals for care of leg
ulcers.)
21. Consult with developers of guidelines used as sources.
Send the adapted guideline to the developers, especially if changes were made to the
recommendations. (Example: No substantive changes were made to recommendations so this step
was not undertaken.)
22. Acknowledge source documents.
Cite references for all source documents in the final document and ensure that any necessary
copyright-related permissions are obtained. (Example: The key guidelines used for the local protocol
were cited.)
Module: After-care planning
23. Plan for aftercare of the adapted guideline.
Decide on a date for review and a plan for a repeat search and modification. (Example: An update 3
years after the initial local protocol was undertaken but no new evidence was found to change the
recommendations.)
Module: Final production
24. Produce a final document of the guideline.
Include details on tools for implementation, including information for patients. The final document
should be easily accessible to end-users. (Example: A formal, guideline-style protocol was written.
Additionally, a 1-page algorithm was developed for community nurses and physicians to use.)
Note: RCN = Royal College of Nursing; SIGN = Scottish Intercollegiate Guidelines Network; RNAO = Registered Nurses Association
of Ontario; PIPOH = Population, Intervention, Professions, Outcomes, and Health care setting; AGREE = Appraisal of Guidelines
Research and Evaluation; ABPI = ankle-brachial pressure index.
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lines Framework for Improvement.
27
They based their classifi-
cation on interviews with focus groups of Norwegian general
practitioners about factors affecting adherence to clinical prac-
tice guidelines for ordering diagnostic images for back pain.
Newly identified barriers were lack of expectancy that adher-
ence to guidelines will lead to the desired process of health
care, emotional difficulty with adherence, improper access to
actual or alternative health care services and pressure to do
otherwise from health care providers and organizations.
27
More recently, the Clinical Practice Guidelines Frame-
work for Improvement was expanded. In a study targeting the
identification of barriers to and facilitators of implementing
shared decision-making in clinical practice, each type of bar-
rier was provided with a specific definition.
28
The intention
was to standardize the reporting of barriers to and facilitators
of use of knowledge in the context of health care.
28
Barriers
were defined as factors that would limit or restrict implemen-
tation of shared decision-making in clinical practice.
29
More
importantly, the Clinical Practice Guidelines Framework for
Improvement was transferred into a list of potential facilita-
tors of use of knowledge in clinical practice.
28
Facilitators
were defined as factors that would promote or help imple-
ment shared decision-making in clinical practice.
Sometimes we forget that the same factor may sometimes be
identified both as a barrier to and as a facilitator of use of
knowledge, showing the importance of developing a more com-
prehensive and integrated understanding of both barriers and
facilitators concurrently.
30,31
The Clinical Practice Guidelines
Framework for Improvement was further extended to include
the attributes of innovation as proposed by the Diffusion of
Innovation theory.
32
As a result, except for the barrier known as
lack of awareness (i.e., not knowing of the existence of a guide-
line) and the facilitator known as awareness (i.e., knowing about
a guideline), the other factors initially proposed by the Clinical
Practice Guidelines Framework for Improvement were potential
barriers or facilitators. One new barrier, “forgetting” (i.e., inad-
vertently omitting to attend to something) was also identified.
This revised version of the Clinical Practice Guidelines
Framework for Improvement was used in a systematic review
of barriers to and facilitators of implementing shared deci-
sion-making in clinical practice.
33
The framework was applied
successfully in extracting data from 41 publications covering
38 unique studies.
33
The corresponding definitions of each of
the potential barriers to and facilitators of use of knowledge in
the health care context are provided in Appendix 1 (available
at www.cmaj.ca/cgi /content/full /cmaj.081232/DC1).
Tools for assessment
To clearly identify barriers to and facilitators of use of knowl-
edge in health care practices, assessment of them in a valid and
reliable fashion is needed. Considerable interest exists in the
idea of instruments for valid and reliable assessment of barriers
to and facilitators of use of knowledge that can be used by vari-
ous end-users who are trying to implement knowledge. Based
on the Clinical Practice Guidelines Framework for Improve-
ment, a tool to assess barriers to adherence to guidelines for
hand-specific hygiene was developed and tested on a group of
21 clinicians of infectious disease.
34
The tool uses a six-point
Likert scale and has two sections: attitudinal statements about
practice guidelines in general and specific statements regarding
hand hygiene. The survey was administered twice, at two-week
intervals. The tool known as Attitudes Regarding Practice
Guidelines was found to have good reliability.
34
However, the
authors concluded that their tool needed to undergo further test-
ing and adaptation as a general measure of potential barriers to
adherence to practice guidelines.
34
One of us (FL) completes regular audits of practice as part of
a primary health care group. In a large, urban site for teaching
family medicine (i.e., with 20 clinical teachers and 24 residents
in family medicine as well as three nurses), the residents
recently completed an audit of ambulatory care of patients with
type 2 diabetes mellitus. One of the clinical teachers supervised
a group of four residents in the completion of this audit. Resi-
dents reviewed the relevant practice guidelines and assessed
their quality using the AGREE checklist. Based on this appraisal
of quality, they retained the recommendations of the guidelines
of the Canadian Diabetes Association. Based on these recom-
mendations, they created a grid for extracting data on whether
the recommendations were implemented. Forty patient charts
were chosen randomly and the percentage of cases that followed
the recommendations of guidelines was calculated.
The results of the audit were presented to the health care
team for discussion. For example, results showed that a test for
glycosylated hemoglobin was performed every three months,
as recommended by the guidelines of the Canadian Diabetes
Association (i.e., level D, consensus) in only 30% of cases.
Based on the Clinical Practice Guidelines Framework for
Improvement, discussion by the group revealed that barriers
perceived by health care providers included lack of agreement
with the recommendation because it was too rigid or artificial,
factors associated with environment such as not having enough
staff to carry out the recommendation, lack of agreement with
the applicability of this recommendation to the population
served by the practice based on the characteristics of the patient
because some patients had very stable results in the past, and
external factors, such as perceived inability to reconcile patient
preferences with compliance to this recommendation.
This scenario shows that groups of providers in real clini-
cal settings can take advantage of this checklist to identify
barriers to carrying out recommendations in guidelines for
practice. Once the barriers are made explicit, solutions can be
expected to be brought forward for the benefit of patients.
Without ignoring that one solution usually does not fit all, this
checklist has the potential to help groups of providers recon-
cile their diverse perspectives because it is evidence-based,
extensive and explicit.
Gaps in the implementation of evidence
Although many current research-based initiatives focus on
implementing guidelines and assessing factors influencing use
of knowledge in health care practices, many challenges remain
that will need to be addressed by rigorous research. First, evalu-
ation of the ADAPTE process is needed to determine its impact
on the implementation of guidelines. Second, validated meth-
ods are needed to assess barriers to and facilitators of the trans-
lation of research into clinical practice.
29,35,36
Researchers and
clinicians may want to consider using existing models that have
been tested, such as the Clinical Practice Guidelines Frame-
work for Improvement (i.e., in its latest version), to conduct
studies on barriers to and facilitators of assessment.
25
Lastly,
more will need to be done to reconcile the recommendations of
practice guidelines to the sharing of care-related decisions with
patients — the core concept of patient-centred care.
This article has been peer reviewed.
Competing interests: None declared.
Contributors: Margaret Harrison, Béatrice Fervers and Ian Graham, who are
founding members of the ADAPTE group, were involved in the development
of the methodology of the manuscript, and conceptualized and drafted the
section on adaptation of guidelines. France Légaré and Ian Graham were
involved in the conceptualization and drafting of the section on assessment of
barriers. All of the authors critically revised the manuscript and approved the
final version submitted for publication.
Funding: No external funding was received for this paper.
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instrument for assessing the quality of clinical practice guidelines: the AGREE
Project. Qual Saf Health Care 2003;12:18-23.
10. Harrison MB, Graham ID, Lorimer K, et al. Leg-ulcer care in the community, before
and after implementation of an evidence-based service. CMAJ 2005; 172: 1447-52.
11. Ray-Coquard I, Philip T, Lehmann M, et al. Impact of a clinical guidelines pro-
gram for breast and colon cancer in a French cancer centre. JAMA 1997;278:
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12. Ray-Coquard I, Philip T, de Laroche G, et al. A controlled “before-after” study:
impact of a clinical guidelines programme and regional cancer network organiza-
tion on medical practice. Br J Cancer 2002;86:313-21.
13. Harrison MB, Graham ID, Lorimer K, et al. Nurse clinic versus home delivery of
evidence-based community leg ulcer care: a randomized health services trial. BMC
Health Serv Res 2008;8:243.
14. Fretheim A, Schunemann HJ, Oxman AD. Improving the use of research evidence
in guideline development: 3. Group composition and consultation process. Health
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practice: evaluating and adapting clinical practice guidelines for local use by health
care organizations. J Obstet Gynecol Neonatal Nurs 2002;31:599-611.
16. Graham ID, Harrison MB, Brouwers M. Evaluating and adapting practice guide-
lines for local use: a conceptual framework. In: Pickering S, Thompson J, editors.
Clinical governance in practice. London (UK): Harcourt; 2003. p. 213-29.
17. Graham ID, Harrison MB, Lorimer K, et al. Adapting national and international
leg ulcer practice guidelines for local use: the Ontario Leg Ulcer Community Care
Protocol. Adv Skin Wound Care 2005;18:307-18.
18. Burgers JS, Cluzeau FA, Hanna SE, et al. Characteristics of high-quality guide-
lines: evaluation of 86 clinical guidelines developed in ten European countries and
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review and proposition for a framework and procedure. Int J Qual Health Care
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20. Shiffman RN, Shekelle P, Overhage JM, et al. Standardized reporting of clinical
practice guidelines: a proposal from the Conference on Guideline Standardization.
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21. Verkerk K, Van Veenendaal H, Severens JL, et al. Considered judgement in evi-
dence-based guideline development. Int J Qual Health Care 2006;18:365-9.
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fessionals: the use of theory in promoting the uptake of research findings. J Clin
Epidemiol 2005;58:107-12.
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tice guidelines? A framework for improvement. JAMA 1999;282:1458-65.
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plain radiography for back pain: implications for classification of guideline barriers
— a qualitative study. BMC Health Serv Res 2003;3:8.
28. Légaré F, O’Connor AM, Graham ID, et al. Primary health care professionals’
views on barriers and facilitators to the implementation of the Ottawa Decision
Support Framework in practice. Patient Educ Couns 2006;63:380-90.
29. Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinical prac-
tice guidelines? A framework for improvement. JAMA 1999;282:1458-65.
30. Graham ID, Logan J, O’Connor A, et al. A qualitative study of physicians’ percep-
tions of three decision aids. Patient Educ Couns 2003;50:279-83.
31. Kennedy T, Regehr G, Rosenfield J, et al. Exploring the gap between knowledge
and behavior: a qualitative study of clinician action following an educational inter-
vention. Acad Med 2004;79:386-93.
32. Rogers EM. Diffusion of innovations. 4th ed. New York (NY): The Free Press; 1995.
33. Légaré F, Ratte S, Gravel K, et al. Barriers and facilitators to implementing shared
decision-making in clinical practice: update of a systematic review of health pro-
fessionals’ perceptions. Patient Educ Couns 2008;73:526-35.
34. Larson E. A tool to assess barriers to adherence to hand hygiene guideline. Am J
Infect Control 2004;32:48-51.
35. Davis DA, Taylor-Vaisey A. Translating guidelines into practice. A systematic
review of theoretic concepts, practical experience and research evidence in the
adoption of clinical practice guidelines. CMAJ 1997;157:408-16.
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Revue Épidémiologique de Santé Publique. 2003;51:65-80.
Correspondence to: Dr. Margaret B. Harrison, School of Nursing,
Queen’s University, 78 Barrie St., Kingston ON K7L 3N6;
ADAPTE Group
Melissa Brouwers, George Browman, Jako Burgers,
Bernard Burnand, Margaret B. Harrison, Béatrice Fervers,
Ian Graham, Jean Latreille, Najoua Mlika-Cabanne,
Louise Paquet, Raghu Rajan, Magali Remy-Stockinger,
Anita Simon, Joan Vlayen and Louise Zitzelsberger
Articles to date in this series
• Straus SE, Tetroe J, Graham I. Defining knowledge transla-
tion. CMAJ 2009;181:165-8.
• Brouwers M, Stacey D, O’Connor A. Knowledge creation:
synthesis, tools and products. CMAJ 2009.DOI:10.1503
/cmaj.081230
• Kitson A, Straus SE. The knowledge-to-action cycle: identi-
fying the gaps. CMAJ 2009.DOI:10.1503/cmaj.081231
The book Knowledge Translation in Health Care: Moving from
Evidence to Practice, edited by Sharon Straus, Jacqueline
Tetroe and Ian D. Graham and published by Wiley-Blackwell
in 2009, includes the topics addressed in this series.
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