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Need for high-standard translation methodology for the dissemination of guidelines

2009; Elsevier BV; Volume: 17; Issue: 12 Linguagem: Inglês

10.1016/j.joca.2009.06.005

1522-9653

Yves Henrotin,

Clinical practice guidelines implementation

Osteoarthritis (OA) is one of the most common chronic musculoskeletal conditions worldwide. Commonly, the hip and the knee are mostly affected by OA, therefore most of the existing recommendations are focused on these joints ((National Institute for Health and Clinical Excellence (NICE), European League Against Rheumatism (EULAR), American College of Rheumatology (ACR), Osteoarthritis Research Society International (OARSI))1Zhang W. Moskowitz R.W. Nuki G. Abramson S. Altman R.D. Arden N. et al.OARSI recommendations for the management of hip and knee osteoarthritis, part II: OARSI evidence-based, expert consensus guidelines.Osteoarthritis Cartilage. 2008; 16: 137-162Abstract Full Text Full Text PDF PubMed Scopus (1921) Google Scholar, 2Altman R. Hochberg M. Moskowitz R. et al.Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update.Arthritis Rheum. 2000; 43: 1905-1915Crossref PubMed Scopus (1846) Google Scholar, 3Jordan K.M. Arden N.K. Doherty M. Bannwarth B. Bijlsma J.W. Dieppe P. et al.EULAR recommendations 2003: an evidenced based approach to the management of knee osteoarthritis: report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT).Ann Rheum Dis. 2003; 62: 1145-1155Crossref PubMed Scopus (1541) Google Scholar, 4Zhang W. Doherty M. Arden N. Bannwarth B. Bijlsma J. Gunther K.P. et al.EULAR evidence based recommendations for the management of hip osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).Ann Rheum Dis. 2005; 64: 669-681Crossref PubMed Scopus (713) Google Scholar. These recommendations, based on both expert consensus and systematic review of research evidence, have been developed to optimize the treatment for hip and knee OA. All these guidelines has been published in English and mainly written by experts from English-speaking countries. The lack of translation from English to the native language is an important barrier to the successful implementation of clinical practice guidelines in the health care system creating a gap between the issuing scientific societies and local health care practitioners. Therefore, to disseminate guidelines in native language is an important step for their implementation in primary care. For this reason, the OA Research Society International promotes the translation of its recommendations in different languages1Zhang W. Moskowitz R.W. Nuki G. Abramson S. Altman R.D. Arden N. et al.OARSI recommendations for the management of hip and knee osteoarthritis, part II: OARSI evidence-based, expert consensus guidelines.Osteoarthritis Cartilage. 2008; 16: 137-162Abstract Full Text Full Text PDF PubMed Scopus (1921) Google Scholar. Recently, the OA section of the French Society of Rheumatology has translated OARSI guidelines in French5Henrotin Y. Marty M. Appelboom T. Avouac B. Berenbaum F. Briole V. et al.French translation of the Osteoarthritis Research society International (OARSI) recommendations for the management of knee and hip osteoarthritis.Rev Rhum. 2009; 76: 279-288Crossref Scopus (12) Google Scholar. Hereafter, a critical analysis of the method used by this group is presented. Improvements in patient care are seen in several areas of medical practice when guidelines are properly followed. The development and publication of guidelines is a necessary, but not a sufficient step for introducing evidence-based practice to the clinical management of patients. In fact, one-third of patients with OA fail to receive recommended care. An Italian survey clearly demonstrates that only 41% of the general practitioners concomitantly used pharmacological and non-pharmacological modalities6Sarzi-Puttini P. Cimmino M.A. Scarpa R. Caporali R. Parazzini F. Zaninelli A. Azeni F. Marcolongo R. Do physicians treat symptomatic osteoarthritis patients properly? Results of the Amica experience.Semin Arthritis Rheum. 2005; 35: 38-42Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar whereas this approach is systematically recommended. The vast majority of patients were managed by general practitioners in primary care with analgesic or non-steroidal anti-inflammatory drugs to relieve pain. In the UK, the recommendations of exercises, patient education and self-management (NICE 2008) are usually observed by physiotherapists, but other modalities such as ultrasound or pulsed shortwave are often used despite the poor or no research evidence supporting their efficiency7Walsh N.E. Hurley M.V. Evidence based guidelines and current practice for physiotherapy management of knee osteoarthritis.Musculoskelet Care. 2009; 7: 45-56Crossref PubMed Scopus (44) Google Scholar. Another survey has reported disparities between physical therapists current use of therapeutic exercise for clinical knee OA and the recent MOVE recommendations in term of the types exercises prescribed, the delivery of the exercises and issues related to adherence8Holden M.A. Nicholls E.E. Hay E.M. Foster N.E. Physical therapists'use of therapeutic exercise fro patients with clinical knee osteoarthritis in the united kingdom: in line with current recommendations?.Physical Therapy. 2008; 88: 1109-1122Crossref PubMed Scopus (67) Google Scholar. These recent studies clearly illustrate the difficulties to implement clinical practice guidelines into practice, even when the guidelines have been produced in English and that the final user mother-language is English. The following factors have been identified as major factors that influence physician adoption of clinical practice guidelines: (1) lack of awareness of gaps in quality of care for people with OA2Altman R. Hochberg M. Moskowitz R. et al.Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update.Arthritis Rheum. 2000; 43: 1905-1915Crossref PubMed Scopus (1846) Google Scholar, the lack of prioritization of OA compared to other inflammatory rheumatic, (3) the difficulty to access this knowledge (lack of time, language problems, etc), (4) an inadequate training in the theory and practice of quality improvement methods, in qualitative evaluation methods and in project management, (5) the difficulty to apply the guidelines in the practitioners' daily practice (inflexible, oversimplified, reluctance for change, lack of agreement, the lack of outcome expectancy), (6) lack of adaptation of knowledge to the local environment of the health care system (health care policy, drug reimbursement, local habits,…), (7) the lack of system to support ongoing review and updating of evidence-based recommendations9Cabana M. rand C. Powe N. Wu A. Modena H. Abboud P. et al.Why don't physician follow clinical clinical practice guidelines? A framework for improvement.JAMA. 1999; 282: 1458-1465Crossref PubMed Scopus (4890) Google Scholar, 10Brand C. Cox S. Systems for implementing best practice for a chronic disease: management of osteoarthritis of the hip and knee.Inter Med J. 2006; 36: 170-179Crossref Scopus (35) Google Scholar. Recently, C Brand11Brand C. Translating evidence into practice for people with osteoarthritis of the hip and knee.Clin Rheumatol. 2007; 26: 1411-1420Crossref PubMed Scopus (16) Google Scholar has proposed strategies and enabling for translating evidence into practice for people with OA of the hip and knee. Among the strategies and enabling identified by this author, the most important were: evidence-based recommendation summary tables, checklist recommendation reminder sheet, involvement of clinician leaders, peer review and scientific meeting presentations, audit and feedback of new evidence-based practice, patient satisfaction assessment, to develop a goal setting care template for health professionals. In 2007, the OARSI has published twenty-five recommendations for the management of hip and knee OA to provide assistance to physicians, allied health care professionals, patients and health care administration1Zhang W. Moskowitz R.W. Nuki G. Abramson S. Altman R.D. Arden N. et al.OARSI recommendations for the management of hip and knee osteoarthritis, part II: OARSI evidence-based, expert consensus guidelines.Osteoarthritis Cartilage. 2008; 16: 137-162Abstract Full Text Full Text PDF PubMed Scopus (1921) Google Scholar. They result from a critical appraisal of existing guidelines, a systematic review of research evidence published from 1945 to 2006 and the consensus opinion of sixteen international experts from four medical disciplines (primary care, rheumatology, orthopaedics and evidence-based medicine). These recommendations cover the use of 12 non-pharmacological modalities, eight pharmacological modalities and five surgical modalities. In order to facilitate their implementation, OARSI has encouraged guidelines translation to different languages. Recently, the osteoarthritis section of the French Society of Rheumatology has published the French version of the OARSI guidelines according to a procedure which included translation and back translation by professional medical translators and approval from a large mutidisciplinary panel of local experts5Henrotin Y. Marty M. Appelboom T. Avouac B. Berenbaum F. Briole V. et al.French translation of the Osteoarthritis Research society International (OARSI) recommendations for the management of knee and hip osteoarthritis.Rev Rhum. 2009; 76: 279-288Crossref Scopus (12) Google Scholar. In contrast to a single translation by a bilingual expert, the translation/back translation method allows to identify the conceptual and cultural discrepancies between the original and translated version. In addition, the OARSI guidelines were discussed in regard to the regional health care practice (prescription habits, health care policy, insurance system, etc) and the feasibility to integrate these guidelines in the local health care policy. This rigorous procedure enables to adapt the international guidelines to the regional medical practice still maintaining the authenticity of the original document. In short, the procedure used for the French translation of the OARSI was the following:a) Only the list of the recommendations was translated, and not the full-length paper.b) The translation was conducted by a multidisciplinary group of local experts from at least three disciplines involved in the management of patients with OA.c) Two native speakers have carried out independent translations of the recommendations from English to the native language. The translators were professional translators with a medical background.d) The two native language versions were compared with one another and with the original version by at least three independent experts with different medical specialization. After discussing all the discrepancies that could arise, a consensus was reached and the two versions were synthesised into one common native language version.e) Two native English speakers mastering the language of translation have carried out a back translation of the native language version into English. Neither of the back translators was familiar with the topic of the recommendations; both were blinded to the English original version; and each has carried out his translation independently. A third bilingual person (native English, translation language as second language) has then compared the two back translations with each other and with the original version and highlighted any conceptual errors or basic inconsistencies in the content of the translated versions, in preparation for the expert committee meeting. A group of three experts and one back translator has examined the back translations, the original version and the notes made in carrying out/comparing the translations and consolidated these to produce a pre-final version of the native language recommendations. This expert committee had to secure semantic and idiomatic equivalence between the native language and English versions of the recommendations. This pre-final version was then submitted to the overall experts of the translation committee for final approval.f) The final version was then discussed by the panel of local experts and commented with regards to the local health care habit and policy. For example, avocado/soybean unsaponifiables, a pharmacological modality not recommended by the OARSI, but commonly prescribed in France was discussed by the experts. This translation methodology is not the “gold standard”, but a model of high-standard template approved by OARSI. It offers many advantages such as – to guarantee translation authenticity, to involve local opinion leaders from various medical disciplines and to adapt the international guidelines to the regional medical practice. Several limitations to this method exist and hinder the guidelines dissemination. It is very expensive and involves professional translators. Further, policy makers, patients and allied health professional do not participate to the adaptation of these guidelines to the regional practice. Obviously guidelines translation play only a small part in the adoption of evidence into practice, but the access to these guidelines in native language is a necessary factor for the implementation of international guidelines in non-English-speaking countries. Reaching high-quality guidelines translation is a guarantee of translation authenticity. Author declared that he didn't received compensation from any company to write this paper.