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The aim of the KHA-CARI Guidelines
To improve the health care and outcomes of paediatric and adult patients with kidney disease by helping clinicians and health care workers to adhere to evidence-based medical practice as often as possible. It is anticipated that the guidelines will serve as both a valuable educational resource and a means of enhancing the quality, appropriateness, consistency and cost-effectiveness of renal health care. The guidelines were initially developed for use in Australia, however they are now being used more widely in the region.
About 100 guideline writers have been involved in researching and writing guidelines so far. Guideline writers are invited to attend a one-day Methods Workshop run by the CARI Office, to help equip them for the task of scanning the literature and writing their Practice Guidelines. This training teaches participants how to critically review and summarise the relevant literature on their topic, how to grade the quality of studies and integrate them into their guidelines, and in general, improves their critical appraisal skills.
Development and review process
Existing guidelines cover the areas of Chronic Kidney Disease; Dialysis and Transplantation. Each guideline comprises various subtopics and their recommendations.
The KHA-CARI Guidelines' development and review process has been recently revised to include:
- evidence rating according to the GRADE system
- peer review by at least 3 peer reviewers
- inclusion of a public consultation phase
- reformatting of existing guidelines with increasing focus on guidelines that are clearly evidence-based
- at least 3 face to face meetings for Guideline Group members to assist with meeting deadlines
Implementation
Implementation projects are undertaken to assess both the impact of KHA-CARI Guidelines on clinical practice as well as the barriers faced by renal units in the implementation of evidence-based guidelines.
CARI undertake research activities that focus on key areas relevant to implementation strategies and the guideline development process.
The CARI process
The kha-CARI Guidelines are strictly evidence-based - that is, they are drawn from the published literature, which is carefully assessed for its level of certainty. Only when the conclusions in a particular area are based on a high degree of certainty is the guideline ratified.
The intention is to write guidelines based on evidence derived from the optimal studies for the specific question.
In July 2009, it was decided that the evidence base should be evaluated and graded using the approach developed by the GRADE Working Group (www.gradeworkinggroup.org). This is consistent with the approach used by many other guideline groups.
CARI continues to use a tiered approach with a clear distinction between 'Guideline Recommendations' and 'Suggestions for Clinical Care'. A Guideline Recommendation requires evidence to be obtained from optimal studies, while a Suggestion for Clinical Care can be written based on evidence obtained from sub-optimal studies, subject to an assessment of the quality of the evidence. The NHMRC levels of evidence table is used to identify optimal and sub-optimal studies.
Adaptation of guidelines
CARI plans to adapt the international renal guidelines produced by Kidney Disease: International Guidelines Organisation (KDIGO) as they are produced from 2009 onwards, based on the ADAPTE process. Adaptation of international guidelines should consider the following five key questions:
- Is there important variation in need (prevalence, baseline risk or health status) that might lead to a different decision?
- Is there important variation in the availability of resources that might lead to different decisions?
- Is there important variation in costs that might lead to different decisions?
- Is there important variation in the presence of factors that could modify the expected effects which might lead to different decisions?
- Is there important variation in the relative values of the main benefits and downsides that might lead to different decisions?
Dissemination of KHA-CARI Guidelines
In order to maximise accessibility to the KHA-CARI guidelines the following dissemination program is used:
- All guidelines are published in supplements to the journal Nephrology (print and web).
- All guidelines are posted on the CARI website with links included on KHA and ANZSN websites.
- Guidelines summaries and links to the guidelines are posted on the US National Guidelines Clearinghouse website.
- Summaries of selected guidelines are written and published in the Australian Family Physician journal.
The KHA-CARI Guidelines are not intended to replace clinical judgement, but rather to complement it.
Acknowledgement to our sponsors The KHA-CARI Guidelines have been developed through the voluntary effort of many participating physicians. Support for the resources needed to allow this process to proceed to completion has come from unrestricted development grants from Amgen Australia, Janssen-Cilag Pty Ltd and Roche Products Australia in 2011.
UPDATED 22 JULY 2011