A Systematic Review of the Content and Quality of Clinical Practice Guidelines for Management of the Neurogenic Bladder Following Spinal Cord Injury - Beyond the Abstract

It’s mind-boggling to think of the resources that culminate in 304 Clinical Practice Guideline (CPG) recommendations cataloged in our recently published systematic review of CPGs for managing neurogenic bladder following spinal cord injury (SCI). The participants in all of the primary studies; the work of synthesizing this into systematic reviews; the expertise involved in evaluating the strength of this evidence, interpreting what it means for practice and developing clear, actionable statements for clinicians.

Yet for all this, CPGs are a job half done. The considerable investment in getting to this point is all wasted if the recommendations are not reflected by practice. Sadly this is often the case. In the early part of this century a number of landmark studies demonstrated that across all areas of medicine and all settings, only half to two-thirds of recommendations are reflected by actual practice.1,2 This spawned the field of knowledge translation (KT; also known as dissemination and implementation science), which examines methods of bridging this evidence-practice gap.3

A key task of KT is to examine why practice is the way it is, and what barriers need to be overcome to optimize healthcare in a specific area. This review was part of a larger program of work to optimize management of the neurogenic bladder in the early acute phase following injury using a KT approach.

Neurogenic bladder is a devastating consequence of SCI. Disturbance in the nerves supplying the bladder leads to disruptions in bladder function that require daily management, predispose people with SCI to urinary tract infections and in so doing, profoundly affect the quality of life and result in large financial costs to the health system.

The current "gold standard" in management of neurogenic bladder is early initiation of intermittent catheterization (IC) rather than prolonged use of indwelling catheters. There is good evidence from both animal and human studies that this reduces the propensity to urinary tract infection (UTI) in those with neurogenic bladder, including following SCI.

We presented this evidence alongside the recommendations from related CPGs to a nationally-convened forum in Australia as part of a major regional SCI conference. The forum was attended by 66 people including people with SCI and their carers, hospital and community nurses, medical specialists, allied health practitioners and researchers.4

The forum discussion illuminated a series of challenges that underline both why the ‘evidence-practice’ gap exists and the importance of understanding and exploring barriers and facilitators to best practice. Four key themes were elucidated.

  • First, considerable variation in catheterization practice across Australia and New Zealand was described – from very early implementation of IC as a default to delays of several months in transitioning from indwelling catheters to IC;
  • Second, a number of barriers to implementing best practice were articulated including emotional and lifestyle considerations following SCI, clinician perceptions of patient readiness for IC and financial and resource considerations – specifically the long-term financial cost of IC which is seldom fully covered by insurance;
  • Third, aligning long-term community IC practice with that instituted in hospital settings was described as very challenging given the numerous trends in neurogenic management over the last few decades that are now reflected in the community-dwelling SCI population and the logistical, practical and attitudinal considerations that are more easily monitored within an inpatient setting;
  • Finally, it was felt that more longitudinal data was needed to bolster the existing evidence base in order to further encourage practice change.4
The forum spawned a two-year project to explore these issues in more depth through qualitative inquiry and pilot a new model of care, the results of which we plan to publish in the near future.

This is but one example of the complexity of bringing CPG recommendations into practice. It is tempting to become disenchanted with the ‘evidence-practice’ gap; but it is also fascinating to unpack and explore the myriad behavioral, institutional and system-wide issues that need to be understood. The science of KT is still young but is showing great promise in helping to harness the hard work of researchers the world over and ensure that eventually, this work can improve lives.

In this sense, the CPG is a critical juncture. It represents a point in knowledge discovery where critical information about ‘who needs to do what’ is packaged and presented. But the last two decades has taught us that it is only the beginning of practice change, and that simply ‘telling people what to do’ – for all the work required to get to this point – is not enough.

Written by: Peter Bragge, Ph.D. B.Physio (Hons.), Associate Professor and Director of Health Programs, BehaviourWorks Australia, Lead, Monash-McMaster Social Systems Evidence Collaboration, Monash Sustainable Development Institute, Monash University, Australia

References:
1.  McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003; 348: 2635–45.
2.  Schuster M, McGlynn E, Brook R. How good is the quality of health care in the United States? Milbank Q 2005; 76: 517–563, 509.
3.  Grimshaw JM, Eccles MP, Lavis JN, Hill SJ, Squires JE. Knowledge translation of research findings. Implement Sci 2012; 7: 50.
4. Goodwin D, Brock J, Dunlop S, Goodes L, Middleton J, Nunn A et al. Optimal Bladder Management Following Spinal Cord Injury: Evidence, Practice and a Cooperative Approach Driving Future Directions in Australia. Arch Phys Med Rehabil 2018; 99: 2118–2121.

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