CARI - Caring for Australasians with Renal Impairment

The CARI Guidelines is an evidence-based project that commenced in 1999. The two bodies assuming responsibility for the CARI Guidelines are the Council of the Australian and New Zealand Society of Nephrology (ANZSN) and the Board of Kidney Health Australia (KHA).

The aim of the CARI Guidelines is 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.

Why have guidelines?

Clinical practice guidelines have proved enormously valuable and are now available in most specialties. It is believed that adherence to the recommendations translates directly into benefits for patients through improved outcomes, benefits for practitioners through improved quality of care, and benefits for providers through improved cost effectiveness. Guidelines are considered to reduce the use of unnecessary, ineffective or harmful interventions, and to facilitate the treatment of patients with maximum chance of benefit, with minimum risk of harm, and at an acceptable cost. Research has shown that clinical practice guidelines can be effective in bringing about change and improving health outcomes.

The guidelines

The CARI Guidelines are divided into three disease stages; Chronic Kidney Disease; Dialysis; and Transplantation A complete listing of guidelines and subtopics and their current status can be found under Guidelines on the CARI website.

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.

The CARI Office assists writers by conducting systematic literature searches, locating relevant trials and preparing summary Evidence Tables for each guideline subtopic.

The CARI process

The CARI process is very demanding of those involved but clearly is an important and worthwhile venture. The updating and revision of all guidelines is scheduled to occur every 3 years, ensuring that guideline contents are kept relatively up to date. Some guideline subtopics will be updated prior to 3 years, when it is considered there is a need to do so. Convenors are expected to prompt this process when they become aware of key new evidence that is relevant to their guideline topic.

The 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.

Implementation of Guidelines

Implementation projects are undertaken to assess both the impact of 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.

Adaptation of guidelines

CARI plans to adapt the international renal guidelines produced by KDIGO (Kidney Disease: International Guidelines Organisation) 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 CARI Guidelines

In order to maximise accessibility to the 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.

Response from the nephrology community

Surveys of Australian and New Zealand nephrologists and renal nurses have been undertaken in 2002 and 2006. Overall, the surveys show support for the CARI Guidelines is high. In the 2006 survey, results show that:

91% agree/strongly agree that CARI provides a useful evidence summary
88% agree/strongly agree the CARI Guidelines cover appropriate areas
60% agree/strongly agree that CARI has significantly influenced their practice
38% say CARI has improved health outcomes for renal patients.

In addition to health practitioners, the overall process from a legal viewpoint has also been favourably endorsed. The CARI Guidelines are not intended to replace clinical judgement, but rather to complement it.

Acknowledgement to our sponsors

The 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 largely from unrestricted development grants from Amgen Australia, Janssen-Cilag Pty Ltd and Roche Products Australia. Genzyme Corporation and Baxter Healthcare Pty Ltd have also given financial support in 2010.

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