Best Practices: Standing on the Shoulders of Giants?

Ronnie Detrich

Wing Institute

Characteristics of Best Practice Guidelines

• Validated evidence-based interventions inform practitioners about which interventions to use.Very specific set of statements about a specific

intervention.

• Best practice guidelines provide broader set of statements about practice.More comprehensive/prescriptive statements than

validated interventions.

Characteristics of Best Practice Guidelines

• Practice guidelines often reflect:Diverse conceptual viewsClinical experienceRecommendations based on weak or non-existent

evidence when a clinician needs to act.

• Practice guidelines are explicitly intended to draw on treatment evidence.

Kazdin, 2000

Function of Best Practice Guidelines

• What Works Clearinghouse (WWC): “bring the best available evidence and expertise to bear on the types of systemic challenges that cannot currently be addressed by single interventions or programs.”

Function of Best Practice Guidelines

• Romanczyk (2008): “intended to inform consumers and service providers about optimal care guidelines as compared to generally accepted practice for conditions or disorders.”Guidelines set a higher standard for care.Many groups purport to having BP guidelines but

they fail to follow accepted methodology for evaluating treatments.

How Best Practices Guidelines are Developed

At least three approaches:1. Individual experts develop guidelines.

Expert Opinion.

2. Group of experts develop. Represents consensus opinion. Draws on the experience of experts.

3. Systematic review of literature: Experts base recommendations on results of

systematic review and expand to more general guidelines for practice.

The “gold standard” for Best Practice Guidelines.

Method: Individual Experts

• Chapters written by single or few authors about comprehensive range of topics in traditional literature review format. Lack of transparency

regarding: Process for selecting

practices. Process for selecting

experts.

How Group Consensus Best Practices Guidelines are Developed

• How the expert panel is developed is important.

If panel is drawn too broadly there is risk of not reaching agreement about:

What is best practice?Which research base to consider?How to decide what constitutes best practice?

How Group Consensus Best Practices are Developed

If expert panel drawn too narrowly:Panel may not be seen as credible.Research base is too narrow and represents only

small range of relevant research.Recommendations may not have high social validity

with larger audience.

Method: Group Consensus

• Large group of “experts.”

• Best practices represent consensus agreement.

• Some effective practices were left out because we could not gain consensus.

Method: Systematic ReviewGold Standard

• U.S Institute of Medicine:Guidelines are based on systematic reviews of the

literature.Expert panel develops broad recommendations

along with the strength of evidence for each recommendation.Process used by New York State Department of Health

Early Intervention: Clinical practice guidelines (1999).National Research Council: Educating Children with

Autism (2001).

Systematic Review Approach

• Applied WWC Evidence standards to review RtI and reading literature.

• Experts developed guidelines for implementing in schools.

• Offers transparency for basis of recommendations.

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Strengths and Limitations of Best Practice Guidelines

Strengths• Bridges the research to

practice gap.• Adds details to

validated evidence-based practices.

• Provides guidance in absence of validated interventions.

Limitations• Recommendations are

generally broad.• Only as good as the

process for developing the recommendations. The “gold standard” is

recent innovation. Has not been

universally adopted.