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Table 1 Adapting the guidelines using the ADAPTE process

From: Adapting clinical practice guidelines for diabetic retinopathy in Kenya: process and outputs

Step Activity Result
Phase I Set up
 1. Establish a resource team The Ophthalmic Services Unit constituted a steering team of five members which developed the terms of reference and prepared a list of 25 potential members for the technical working group (TWG), who were subsequently invited to the group
 2. Determine criteria for selection and select a topic using criteria DR was selected because it is a public health concern and there is variation in standards of care
 3. Check if adaptation is feasible Evidence-based guidelines were already in use internationally, and there was high interest from the Ministry of Health, clinicians, and other users to develop guidelines
 4. Identify necessary resources and skills There was high level of commitment by members of the TWG. The Fred Hollows Foundation committed to provide funds, and the required expertise was available: retinal specialists, public eye health specialists, endocrinologists, diabetes educators, epidemiologists, search and retrieval of information, critical appraisal, research, policy, guideline development, and eye health systems. A need for input from other professions in the multidisciplinary care team for type 1, type 2, and gestational diabetes was identified
 5. Complete tasks of the set-up phase Members of the group decided to function as a working group coordinated by the Ophthalmic Services Unit. A set of guiding principles to foster development of the guidelines was adopted (Table 2). Potential conflicts of interest were explored, and there were none to declare
 6. Write the plan for adaptation A timeline for completion, list of additional resource persons to be included, list of outputs to be developed in conjunction with the guidelines and task allocation among the TWG members were agreed upon
Phase II Adaptation
 7. Determine and clarify the question A PIPOH summary was prepared (Table 3). The areas of interest for standards of care were determined as screening, diagnosis and management of DR, and the management of DM in relation to DR, within the existing care pathway for PLWD in the Kenyan health system
 8. Search for guidelines and other relevant documentation The TWG searched for relevant DR guidelines and evidence on DR interventions in systematic reviews
 9. Screen the retrieved guidelines and record their characteristics and content The recommendations of the guidelines for screening, diagnosis and management of DR, and the management of DM in relation to DR was reviewed, extracted, and compiled in summary tables. Evidence from Cochrane systematic reviews was also reviewed
 10. Eliminate a large number of the retrieved guidelines using the AGREE instrument The rigor dimension of the AGREE II tool was utilized to eliminate guidelines that did not meet the stipulated criteria
 11. Assess the quality of the guideline The AGREE II instrument was used to scrutinize the quality of the guidelines
 12. Assess the currency of the guideline The guidelines retrieved were sufficiently current, and we did not identify any new evidence
 13. Assess the content of the guideline Recommendations for screening, diagnosis, grading, referral and treatment were examined and did not differ significantly between guidelines
 14. Assess the consistency of the guideline There was clear consistency between the evidence from systematic reviews, the interpretation of the evidence, and the recommendations in the guidelines in all the areas of interest
 15. Assess the acceptability and applicability of the recommendations Care was taken to ensure the recommendations are not in conflict with other local guidelines and to appraise the implications of the guidelines on health service delivery
 16. Review assessments The results of the assessment of the guidelines were discussed in meetings of the TWG
 17. Select among guidelines and recommendations to create an adapted guideline The ICO guideline for DR was the main guideline used because the recommendations compared well with the other high-quality DR guidelines and the practice-based recommendations were well-stated
 18. Prepare a draft of the adapted guideline The facilitators of the working group compiled the results of the deliberations and wrote the draft guideline document
Phase III Finalization
 19. Seek feedback on the draft guideline from those who would be using it Three revisions of the draft were circulated for comment to TWG members as well as surgeons, pediatricians, ophthalmologists, Kenya Defeat Diabetes Association, vitreoretinal surgeons, physicians, diabetes educators for agreement and identification of gaps
 20. Consult with endorsement bodies The Ministry of Health adopted the guidelines
 21. Consult with developers of guidelines used as sources No substantive changes were made to recommendations so this step was not undertaken
 22. Acknowledge source documents The key guideline documents and other resources used have been acknowledged through attribution
 23. Plan for aftercare of the adapted guideline A review date was planned for 5 years. Monitoring indicators were also identified. Pilot-testing has been used to check for usability. Distribution will be through electronic and print copies
 24. Produce a final document of the guideline and other outputs The following additional outputs were produced (along with the guideline): posters and brochures for patient information, posters, brochures and checklist to be used by clinicians, workshop slides for training health workers, quality assurance guidelines