A COMMON APPROACH ALEX SANCHEZ-VIVAR Developing Evidence-Based Guidelines for Health Protection - An...
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Transcript of A COMMON APPROACH ALEX SANCHEZ-VIVAR Developing Evidence-Based Guidelines for Health Protection - An...
A COMMON APPROACH
ALEX SANCHEZ-VIVAR
Developing Evidence-BasedGuidelines for Health Protection
- An overview of the process -
Developing Evidence-BasedGuidelines for Health Protection
- An overview of the process -
Moriarty: “Everything I have to say has already crossed your mind.”
Sherlock: “Probably my answer has crossed yours.”
Moriarty: “Everything I have to say has already crossed your mind.”
Sherlock: “Probably my answer has crossed yours.”
Presentation OverviewPresentation Overview Presentation OverviewPresentation Overview
1. Intro: the Health Protection Network (HPN)
2. Why does Evidence-Based Practice matter to us? Rationale & background
3. A systematic approach to produce guidance for HP in ScotlandDevelopment of evidence-based guidelines
1. Intro: the Health Protection Network (HPN)
2. Why does Evidence-Based Practice matter to us? Rationale & background
3. A systematic approach to produce guidance for HP in ScotlandDevelopment of evidence-based guidelines
1. The Health Protection Network (HPN) in Scotland
1. The Health Protection Network (HPN) in Scotland
The Health Protection Network (HPN) is a network of existing professional organisations and networks in the health protection community across Scotland.
It aims to promote, sustain, and coordinate good practice.
The HPN does this by adopting, promoting and disseminating a systematic approach to develop evidence-based guidelines, as well as by ensuring an appropriate workforce development plan is in place and complied with.
MEMBERSHIP • Scottish CPHM (CD/EH) Group• Health Protection Nurses Specialist (Scotland) Network (HPNS) • Health Protection Scotland (HPS) • Infection Prevention Society (IPS) • The Royal Environmental Health Institute of Scotland (REHIS) • Scottish Infection Research Network (SIRN) • Scottish Microbiology Virology Network (SMVN) and the Scottish Clinical Virology Consultants Group (SCVG)• Scottish Public Health Network (ScotPHN) • Society of Chief Officers of Environmental Health (SoCOEH) • Health Protection Education Programme (HPS/NES) • Public Representative
• Why does evidence-based practice matter to us?
Rise of Evidence-Based Medicine
• First described in 1992• A new approach to teaching medicine• A “revolution” in medical practice• Other “evidence-based” approaches: ethics,
psychotherapy, occupational therapy, dentistry, nursing, and librarianship
Factors Driving EBM
• Overwhelming size of the literature• Inadequacy of textbooks• Difficulty synthesizing evidence and
translating into practice• Increased number of RCTs• Available computerized databases• Reproducible evidence strategies
Sackett DL et al; Churchill Livingstone, 2000
Definition of EBM
• “The integration of best research evidence with clinical expertise and patient values.”
Steps of EBM
• Convert the need for info. into an answerable question
• Track down the best evidence• Critically appraise that evidence• Integrate the appraisal with one’s clinical
expertise and the individual patient• Evaluate
Sackett DL. EBM: how to practice and teach EBM. Churchill Livingstone 2000
Critique of EBM
• De-emphasizes patient values• Doesn’t account for individual variation• Devalues clinical judgment• Leads to therapeutic nihilism
Development of EBPH
• Jenicek (1997) published a review discussing epidemiology, EBM, EBPH
• Epidemiology described as the foundation of both EBM and EBPH
• EBPH unique in using complex interventions with multiple community and societal issues
Jenicek M. J Epidemiol 1997;7:187-97
Definition of EBPH (1)
• “EBPH is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of communities and populations in the domain of health protection, disease prevention, health maintenance and improvement.”
Jenicek (1997)
Strong evidence supports that…
“teaching is not effective on Friday afternoons”
Strong evidence supports that…
“teaching is not effective on Friday afternoons”
• Trust? – sourceTrust? – source
• Evidence – Identified and synthesised?Evidence – Identified and synthesised?
• Recommendations link with the evidence?Recommendations link with the evidence?
• Validation Validation improve practice? improve practice? implementation implementation
Interpretation of Interpretation of ““communications”communications”
“Half of what we are taught as medical students will in ten years have been shown to be wrong. The trouble is, none of teachers knows which half.”
Dr Sydney Burrell, Dean of Harvard Medical School (2000)
Health Care / Medical Sciences Literature -Health Care / Medical Sciences Literature -
Good Practice GUIDELINES
“Systematically developed statements to assist practitioner and patient (public) decisions about appropriate public health interventions for specific circumstances”
Derived from: Institute of Medicine Committee to Advise the Public Health Service on Clinical Practice Guidelines. Clinical Practice Guidelines: Directions for a new program. Washington DC: National Academy Press, 1990.
Concepts
What makes a good guideline?
“Should provide extensive, critical and well-balanced information on the benefits and limitations of various interventions so that the practitioner can carefully judge individual cases”
Derived from: Subcommittee of WHO. Summary of the 1993
WHO. BMJ 1993; 307: 1541-1546
Concepts
Concepts
Guidelines Purpose
“To make explicit recommendations with a definite intent to influence what physicians do”
Derived from: Hayward RSA, Wilson MC, Tunis SR, Bass EB,
Guyatt G, for the Evidence-Based Medicine Working Group. Users’ guides to the Medical Literature. VIII How to use Clinical Practice Guidelines. A Are the
Recommendations Valid? JAMA 1995< 274> 570-574
What makes a good guideline?
• Valid• Reproducible• Cost-effective• Representative / multidisciplinary• Clinically applicable• Flexible • Clear • Reviewable• Amenable to clinical audit
Criteria
NHS Executive. Clinical Guidelines. Leeds: NHSE, 1996
Potential benefits of Good Practice Guidelines
• For the public / patients
• For healthcare professionals
• For healthcare systems
Adapted from Woolf SH et al. Potential benefits, limitations and harms of clinical guidelines. BMJ 1999: 318: 527-530
Potential benefits for patients / the public
Better quality of care
Improve health outcomes
Improve consistency of care
Inform patients / public about what health professionals should be doing
Empower public to make more informed choices
Influence public policy
Promote distributive justice
Potential benefits for healthcare professionals
Better quality of management decisions
Reassure healthcare professionals that practice / intervention is appropriate
Provide explicit recommendations to guide care / public health interventions
Reduce outdated, ineffective or wasteful practice
Support quality improvement initiatives
Inform the research agenda by highlighting gaps in evidence
Potential benefits for healthcare systems
Improve efficiency
Optimise value for money
Demonstrate adherence to guidelines may improve public image
What can GUIDELINES offer to improve the standard of practice?
• Provide clear statements and standards for the delivery of care/service locally• Clarify roles and responsibilities• Support the implementation of evidence-based practice• Promotes high quality, effective care / service• Support risk assessment and management• Provide opportunities for the public to become involved in developing services• Provide a source of information for the CG Committee• Provide audit information• Promote high quality record keeping
How are evidence-based guidelines developed?
1. Identifying and refining the subject area of a guideline
2. Running guideline development groups
3. Identifying and assessing the evidence
4. Translating evidence into a clinical practice guideline
5. Reviewing and updating guidelines
Shekelle PG, Woolf SH, Eccles M, Grimshaw J. Developing guidelines. BMJ 1999: 42: 67-81
COMPOSITION OF THE GUIDELINE DEVELOPMENT GROUP
DEFINE RESOURCE CONSEQUENCES
CONSULTATION & PEER REVIEW
EDIT & PUBLICATION
FORMULATION OF AUDIT & PEER REVIEW
FORMATION OF RECOMMENDATIONS & GRADING
IDENTIFICATION & EVALUATION OF EVIDENCE
TOPIC SELECTION & SCOPE
HPS GUIDELINES Development Proposal
CPD
SELECTION OF GUIDELINE TOPICS
FORMATION OF RECOMMENDATIONS
CONSULTATION AND PEER REVIEW
PRESENTATION AND DISSEMINATION
LOCAL IMPLEMENTATION
SYSTEMATIC LITERATURE REVIEW
COMPOSITION OF THE GUIDELINE DEVELOPMENT GROUP
AUDIT AND REVIEW
ORGANISATION OF GUIDELINE DEVELOPMENT
SIGN GUIDELINES
Scottish Intercollegiate Guidelines Network. SIGN 50: A Guideline developers’ handbook, Edinburgh, March 2004
PREPARE THE WORKPLAN
IDENTIFY THE EVIDENCE
REVIES AND GRADE THE EVIDENCE
CONSULTATION DRAFTS AND PEER REVIEW
FINAL GUIDELINE
FORMULATE THE CLINICAL QUESTIONS
FORM THE GUIDELINE DEVELOPMENT GROUP (GDG) AND MEETINGS
REVIEW AND UPDATE WITHIN AND AGREED TIMEFRAME
SCOPE THE GUIDELINE
CREATE GUIDELINE RECOMMENDATIONS
NICE
National Institute for Clinical Excellence. Guideline Development Methods. London, Feb 2004
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COMPOSITION OF THE GUIDELINE DEVELOPMENT GROUP
DEFINE RESOURCE CONSEQUENCES
CONSULTATION &PEER REVIEW
EDIT & PUBLICATION
FORMULATION OF AUDIT & PEER REVIEW
FORMATION OF RECOMMENDATIONS & GRADING
IDENTIFICATION & EVALUATION OF EVIDENCE
TOPIC SELECTION & SCOPE
CPD
HPS Proposal GUIDELINE DEVELOPMENT PROCESS
Subject
Groups
Evidence
Editing
Review
Health Health Protection Protection Network (HPN) Network (HPN) Guideline Guideline Development Development Framework Framework
2. A systematic approach to produce guidance for HP in ScotlandDevelopment of evidence-based guidelines
2. A systematic approach to produce guidance for HP in ScotlandDevelopment of evidence-based guidelines
1. Developing guidelines de novo
• Guidelines on Management of Legionella outbreaks and clusters in the community ( in collaboration with SIGN )
• Guidelines on Prophylaxis and Management of Rabies in Humans
2. Adapting existing guidelines
2.1. From a validated group of guidelines Guidelines on Risk Communication (appraisal of 7
guidelines)
2.2. Local adaptation of one validated guideline Guidelines on Tuberculosis (based on the NICE guidelines)
2.3. Review / revision of existing (older) local Scottish Guidance Guidance on managing E coli O157
1. Developing guidelines de novo
• Guidelines on Management of Legionella outbreaks and clusters in the community ( in collaboration with SIGN )
• Guidelines on Prophylaxis and Management of Rabies in Humans
2. Adapting existing guidelines
2.1. From a validated group of guidelines Guidelines on Risk Communication (appraisal of 7
guidelines)
2.2. Local adaptation of one validated guideline Guidelines on Tuberculosis (based on the NICE guidelines)
2.3. Review / revision of existing (older) local Scottish Guidance Guidance on managing E coli O157
“A guideline which fulfils all the institute's requirements
is like the Holy Grail: worth striving for,
but unattainable by mere mortals”
GENE FEDER, St Bartholomew's and the Royal London Medical College, 1993
“A guideline which fulfils all the institute's requirements
is like the Holy Grail: worth striving for,
but unattainable by mere mortals”
GENE FEDER, St Bartholomew's and the Royal London Medical College, 1993
Development of evidence-based guidelinesDevelopment of evidence-based guidelines
• A common methodology• A common methodology
• Validated (SIGN 50)• Validated (SIGN 50)
1. Topic selection and Scope
2. Completion of the GDG
3. Identification and evaluation of the evidence
• Appraisal tools (SIGN 50)
• AGREE instrument
4. Formulation of recommendations
5. Editing, publishing and implementing
1. Topic selection and Scope
2. Completion of the GDG
3. Identification and evaluation of the evidence
• Appraisal tools (SIGN 50)
• AGREE instrument
4. Formulation of recommendations
5. Editing, publishing and implementing
.
.
.
.
.
.
.
.
Resources• Stakeholders capacity in harmony with business continuity• Training issues• Prioritisation criteria
Quality Assurance• Competence in search strategy / appraisal skills• Criteria to quality assure our own guidance
Pool of Evidence• Intrinsic limitations in the hierarchy of evidence• Interpretation of epidemiological evidence• Integration of extrapolated and induced evidence
Grading of Recommendations
• Limitations in adopting conventional grading of recommendations• Value of expert opinion – shared knowledge from practice
Consultation and Peer Review
• Access to experts• Consultation beyond geographical boundaries• Applicability and implementation issues
3. Challenges in developing E-B Guidelines for health protection
3. Challenges in developing E-B Guidelines for health protection
Formulating recommendationsFormulating recommendations
GradingGrading
Strength of recommendation (1)
A – high level of evidenceBCD GPP – Good Practice Point
Strength of recommendation (1)
A – high level of evidenceBCD GPP – Good Practice Point
Pool of EvidenceHierarchy of evidence
Pool of EvidenceHierarchy of evidence
3. Challenges in grading recommendationsIntrinsic to the nature of Health Protection (1 of 2)
3. Challenges in grading recommendationsIntrinsic to the nature of Health Protection (1 of 2)
RCTRCT
Systematic ReviewsSystematic Reviews
CohortCohort
Case controlCase control
Case ReportCase Report
Case seriesCase series
(1) Grades of Recommendation from SIGN 50. Jan 2008
Grey LiteratureGrey Literature
Legislation
Codes of Practice
Legislation
Codes of Practice
E-B Guidelines onHealth ProtectionHPN / HPS
3. Challenges in grading recommendations
Intrinsic to the nature of HP (2 of 2)
3. Challenges in grading recommendations
Intrinsic to the nature of HP (2 of 2)
no
no
some
D
GPP
no
no
some
D
GPP
E-B Guidelines for Health Protection
E-B Guidelines for Health Protection
??
4. Key Considerations4. Key Considerations
• Good understanding of what’s needed to produce good quality guidelines:
• Provide clear statements and standards for the delivery of care/service• Clarify roles and responsibilities• Support the implementation of evidence-based practice• Promotes high quality, effective care / service
• Propose a validated method to systematically produce guidelines… and test it… test it… test it… • acknowledge limitations – investment / prioritisation• try resolve the scientific challenges amongst the wider community
• A path to solution – Collaboration (NICE/SIGN… RKI/ECDC… HPA)
• Good understanding of what’s needed to produce good quality guidelines:
• Provide clear statements and standards for the delivery of care/service• Clarify roles and responsibilities• Support the implementation of evidence-based practice• Promotes high quality, effective care / service
• Propose a validated method to systematically produce guidelines… and test it… test it… test it… • acknowledge limitations – investment / prioritisation• try resolve the scientific challenges amongst the wider community
• A path to solution – Collaboration (NICE/SIGN… RKI/ECDC… HPA)
““In order to move forward, we need two legs: In order to move forward, we need two legs: action and reflection”action and reflection”
Gaudi
ThanksAlex Sánchez-VivarAlex Sánchez-Vivar
[email protected]@nhs.net
What are evidence based guidelines?
Mechanisms to improve the quality of health care and decrease costs and utilisation
Recommendations devised to influence decisions about health interventions
Tools to outline procedures which operate the implementation of evidence-based practice
Decision tools to close gaps between current and optimal practiceDecision tools to close gaps between current and optimal practice
Good Practice GUIDELINES
Derived from: Institute of Medicine Committee to Advise the Public Health Service on Clinical Practice Guidelines. Clinical Practice Guidelines: Directions for a new
program. Washington DC: National Academy Press, 1990.
Good Practice GUIDELINES
Derived from: Institute of Medicine Committee to Advise the Public Health Service on Clinical Practice Guidelines. Clinical Practice Guidelines: Directions for a new
program. Washington DC: National Academy Press, 1990.
“Systematically developed statements to assist practitioners (and public) to make decisions about appropriate public health interventions
for specific circumstances”
“Systematically developed statements to assist practitioners (and public) to make decisions about appropriate public health interventions
for specific circumstances”