How can the Health Sector consistently produce

high quality Clinical Practice Guidelines (CPGs)?

by Janielle Kristine Go and Christelle Joy Reyes
AHEAD Fellows, Health Policy and Systems Research Track
Based on Developing Standardized Processes for CPG Appraisal and Development
by Leonila F. Dans, Maria Asuncion A. Silvestre, Beverly Lorraine C. Ho, Ma. Lourdes S. Imperial, and Red Thaddeus D. Miguel

Clinical Practice Guidelines (CPGs) are From an earlier study, it was found that CPG
recommendations intended to optimize patient care, development in the Philippines is primarily constrained
which are informed by a systematic review of evidence by inadequate human and financial resources, and
and an assessment of the benefits and harms of suffers from unmanaged Conflicts of Interests (COIs).
alternative care options. The study recommended that a manual/guide be
developed and an oversight function be institutionalized
CPGs are important for producing regulatory policies, to ensure consistent production of high quality CPGs.
designing public health programs, developing
PhilHealth benefit packages, and supporting Health This brief summarizes the key ideas outlined in a
Technology Assessments (HTA). forthcoming DOH Manual on CPG Development.

What are the different phases of CPG Development?

1 TOPIC PRIORITIZATION <75%. After at least 4 favorable recommendations
Topics that are feasible and recognized of the 5 QRP members, the CPG will be submitted
as a priority are selected for CPG to the DOH for final approval.
development. Prioritization is based on the
following criteria: 4 DISSEMINATING APPROVED CPGS
i. Disease Burden The following means may be utilized to
ii. Controversy disseminate newly-approved CPGs.
iii. Cost-effectiveness • DOH memo to stakeholders
iv. New Evidence • DOH newsletter and alerts to appropriate
v. Potential Impact agencies
vi. Public and Provider Interest • Press release, news articles, social media
vii. Variation in Care • Tri-media advertising
viii. Sufficiency of Evidence • Fora, conferences, trainings, and
ix. Timeliness implementation workshops
• Information education and communication
2 CPG GENERATION materials for laymen and patients
The basic steps are as follows: • Mobile applications
i. Formulating Clinical Questions
ii. Incorporating Equity 5 MONITORING AND EVALUATION
iii. Searching for Existing CPGs and Adaptation Assessment of CPG effectiveness are
iv. Systematic Review incorporated in the CPG protocol, which
v. Assessing the Evidence entails collection and synthesis of data reflecting
vi. Arriving at Consensus its impact. Impact evaluation should be performed
vii. Producing the Guideline before the release of the CPG and 1-2 years
thereafter.
EVIDENCE APPRAISAL
3 A methodological review of the Additionally, it is advisable to revise a CPG every 3
completed CPG draft will be carried out years to coincide with the turnover of new evidence
by a Quality Review Panel (see clearinghouse on the topic. The National Guideline Clearinghouse
below) using the AGREE II instrument. The (NGC) will regularly assess guidelines for review
acceptable cut off for the AGREE score will be set and/or update.
at an overall mean of 75%, with no domain scoring

Who are accountable for quality CPG development?

CPG developers - “ensure continuous CPG appraisers - “ensure rigour”
development” The appraisers, or the quality review panel
Any person, body, organization, or institution comprised of a DOH official, content experts,
that has technical capacity on clinical research and methodologists, is convened on an ad-hoc
development and research expertise. CPG developers basis to review whether a CPG has met the quality
should have at least one each of the following: standards set in the manual and thus merit adoption as
1. CPG/GRADE methodologist national guidelines, or or if further revisions are required.
2. Clinical epidemiologist or evidence-based health care

What are the types of COIs?

COIs are defined as circumstances that create risks on primary interest to be unduly influenced by a secondary
interest based on individual judgment or action. The 2 types of COI are Financial COI and Intellectual or Academic COI.
Financial COIs Intellectual COIs
Direct commercial COIs Direct commercial COIs
• employment • published paper on topic at hand
• consultancies • guideline grant support
• stock ownership • personal beliefs
• honoraria and/or gifts • committee position holder
• paid expert testimony • advocacy group member
• patents or patent applications membership • family members with the same condition/disease addressed
• industry sponsored research or travel for the participant or by the CPG
family members

Non-commercial COIs
• research grants
• support from governments, foundations, or nonprofit
organizations
• economic relations with specific companies or groups
• acquisition of research funds

How can COIs be managed in the CPG development process?

Primary COI Secondary COI
Individuals who are identified with Primary COI cannot Individuals with secondary COI may be part of the CPG
be CPG developers and Clearinghouse but can only developing team or clearinghouse and participate in
participate in discussing evidences. evidence discussion, indicated that COIs were declared.
i. Monetary relations with industry/company i. Monetary relations with industry/company
for 48 months covering interventions
ii. Authorship in research study ii. Authorship in reviews or other
related CPGs

© Department of Health - Philippines, 2018

The content of this publication does not reflect the official opinion of the Department of Health or Philippine Council for Health Research and Development. Responsibility
for the information and views expressed in this publication lies entirely with the author(s). Reproduction is authorized provided the source is acknowledged.

Advancing Health through Evidence- To access the full text of this article or other research Advisory Board
Assisted Decisions with Health Policy projects funded by the DOH, contact: Usec. Mario Villaverde, MD, MPH, MPM, CESO I
and Systems Research (AHEAD-HPSR) Dir. Kenneth Ronquillo, MD, MPHM, CESO III
operationalizes F1+ for Health’s Research Center for Health System Development
commitment to instill a culture of (RCHSD) Editors
research and strengthen internal analytic [Link]@[Link] Beverly Lorraine Ho, MD, MPH
capacity in the Department of Health 651-7800 loc 1326 Barbara Michelle de Guzman, MSN, RN
and build health policy systems research
capacity within the sector. Research Division - Health Policy Development and Publication Manager
Planning Bureau Juanita Valeza
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