Current Care Guidelines

Jorma Komulainen

1st April 2016 (April Fool’s Day)

Disclosure of Interests

• MD, PhD, Adjunct professor, specialist in paediatric

endocrinology

• Editor-in-Chief, Current Care Guidelines, Finnish Medical

Society Duodecim

• Member of the EBMeDS editorial team, Duodecim Medical

Publications Ltd

• Consultant paediatric endocrinologist, South-Carelia central

hospital

• Research activities: paediatric endocrinology, paediatrics,

health care, eHealth, EBM

Content

• Duodecim

• Evidence based medicine

• Current Care Guidelines

• Terveysportti and Terveyskirjasto

• Criteria for non-acute care (Ministry of Health)

• HTA in Finland

Finnish Medical Society Duodecim

• Founded in 1881 to advance medicine in Finnish

• Largest scientific society in Finland

– 21 000 individual and 100 society members

• Main activities

– Continious medical education

– Support medical scientific research (grants etc)

– Scientific periodical ”Duodecim”

– National clinical practice guidelines (Current Care)

– Professional and social support of physicians

– Duodecim Medical Publications Ltd

Duodecim Medical Publications Ltd

• Leader in medical publishing sector in Finland

• Owned by the Society, not-for-profit

• Large collection of medical textbooks

• Growing collection of educational web-courses

• EBMG (collection of around 1000 short guidelines, targeted

for on-site use in primary health care, easy-to-use)

• EBMeDS; decission support integrated in electronic health

records

• Terveysportti: A health portal for professionals

• Terveyskirjasto: A health portal for lay people

EBM: ”If you are not experienced in intubation, use the laryngeal mask.”

What is evidence-based medicine, EBM?

• A combination of

– Most reliable scientific evidence

– Clinical experience

– Patient’s wish and expectations

Sackett D, Straus SE, et al. Ed. Evidence-based Medicine Churchill Livingstone 2000

What is EBM?

• A framework for how to assess clinical research

in a way that is

– uniform

– theoretically reasonable

– systematic

– understandable to the clinician

• The evaluation should provide an understanding

on how valid and applicable that particular

clinical research data is.

PICOS; the basics for assessment of

validity and applicability

What is your clinical question? To evaluate

effectiveness of treatment your question includes:

• Patients

• Intervention

• Comparator

• Outcome

• Study design

GRADE

Jousimaa et al. Duodecim 2011

Grading the evidence (treatment A vs.

treatment B)

• A = high quality evidence; we trust that treatment A is better than

treatment B and should be recommended.

• B = moderate quality evidence; we believe that treatment A is better

than treatment B, but further studies may still change the size of the

effect. Treatment A should be recommended to most patients.

• C = low quality evidence; it seems that treatment A may be better

than treatment B, but more studies are needed. Treatment A may be

recommended, but other options should be discussed.

• D = no direct evidence; the experts recommend treatmen A over

treatment B, but studies are needed. Various treatment options

should be discussed.

What are clinical practice guidelines?

Clinical practice guidelines are statements that

include recommendations intended to optimize

patient care that are informed by a systematic

review of evidence and an assessment of the

benefits and harms of alternative care options.

Institute of Medicine (IOM) 2011

Assessment of guidelines validity; G-I-N

(1/2)

Composition of guideline development group

A guideline development panel should include diverse and relevant stakeholders, such as health professionals, methodologists, experts on the topic, and patients.

Decision-making process A guideline should describe the process used to reach consensus among the panel members.

Conflicts of interest A guideline should include disclosure of the financial and non-financial conflicts of interest.

Scope of the guideline A guideline should specify its objective(s) and scopes.

Methods A guideline should clearly describe the methods used for the guideline development in detail.

Evidence reviews

Guideline developers should use systematic evidence review methods to identify and evaluate evidence related to the guideline topic.

Assessment of guidelines validity; G-I-N

(2/2)

Guideline recommendations

A guideline recommendation should be clearly stated and based evidence of benefits; harms; and, if possible, costs.

Rating of evidence and recommendations

A guideline should use a rating system to communicate the quality and reliability of both the evidence and the strength of its recommendations.

Peer review and stakeholder consultations

Review by external stakeholders should be conducted before guideline publication.

Guideline expiration and updating

A guideline should include an expiration date and/or describe the process that the guideline group will use to update recommendations.

Financial support and sponsoring organization

A guideline should disclose financial support for the development of both the evidence review as well as the guideline recommendations.

Current Care Guidelines

• In Finnish: Käypä hoito -suositukset

• Started in 1994

• Produced with public funding by the Finnish

Medical Society Duodecim in cooperation with

various medical specialist societies

• Alltogether 104 guidelines available for all

(www.käypähoito.fi)

• Updated on a regular bases

What is the purpose of clinical

practice guidelines?

• Excellent instruments to summarize evidence

and to relate evidence to practice

• Guideline is not a cookbook

– Tailor to the needs of your patient

– Physician is responsible of the treatment

decisions, which should be decided in accordance

with the patient

How the purpose of guidelines is

defined in Current Care Guidelines

• To improve quality of care

• To obtain equal care to all patients

• Independent, national, evidence based

• For professionals and patients

•

Clinical

guidelin

es • 18

Functional features and user support of

Current Care guidelines by Finnish

Medical Society Duodecim

• Interactive graphs

• Counters

• Summary of evidence tables linked within text

• References linked to text

• Videos

• www.käypähoito.fi

Terveysportti

• National health portal produced by Duodecim

Medical Publications Ltd, and used in all hospitals

and health centres in Finland

• Most valuable electronic tool for clinicians and

other health care professionals

• Licenced, right to use required

• Includes many databases, some of them in

English

– EBMG, Cochrane, DynamedPlus, MacMaster

• www.terveysportti.fi

Terveyskirjasto

• High quality health portal for lay people,

produced by the Duodecim Medical Publications

Ltd

• Payed by hospital districts to be open to all

people living in Finland

• www.terveyskirjasto.fi

Criteria for non-acute care

• Ministry of Health publishes criteria for non-acute

care (kiireettömän hoidon perusteet) to give

guidance when patients should be referred to

specialist care

– Based on Current Care Guidelines, when possible

• Available (pdf-version) in

http://urn.fi/URN:ISBN:978-952-00-3520-4

• Also available via Terveysportti

Health technology assessment (HTA)

• Fimea (Finnish Medicines Agency) is responsible

for drug HTA

– http://www.fimea.fi/web/en/development/therapeutic_and

_economic_value_of_medicines

• THL (National Institute for Health and Welfare)

produces other HTA’s and also runs a database of

international HTA’s (Ohtanen)

– https://www.thl.fi/en/web/thlfi-en

– https://meka.thl.fi/ohtanen/default.aspx

Conclusions (1); guiding Finnish health

care with knowledge

Publications Organization

HTAs National Institute for Health and Welfare (Finohta) with hospital districts

HTAs for drugs Finnish Medicines Agency (Fimea)

National comprehensive CPGs Medical Society Duodecim (Current Care Guidelines) with medical specialist societies

On site guidelines Duodecim Medical Publications Ltd (EBMG Guidelines)

Decision support integrated in EMRs

Duodecim Medical Publications Ltd (EBMeDS)

Conclusions (2); EBM

Cochrane Handbook

Adapted from: Tannahill A. Beyond evidence - to ethics: a decision-making framework for health promotion, public health and health improvement. Health Promotion International 2008;23:380-390.

Treatment decisions

Ethics in society

Clinical research

Basic research

Knowhow Resources

Patient as a whole Patient values and preferences

Laws

Art

of Medicine

Guidelines

Science

of Medicine

Conclusions (3); shared decision making

Thank you!

”The temptation to form

premature theories upon

insufficient data is the bane

of our profession”

Sherlock Holmes in The

Tragedy of Birlstone