developing a guideline the ebm workshop a.a.haghdoost, md; phd of epidemiology [email protected]

Developing Developing a guidelinea guideline

The EBM workshopThe EBM workshop

A.A.Haghdoost, MD; PhD of EpidemiologyA.A.Haghdoost, MD; PhD of [email protected]@kmu.ac.ir

EBM workshop Developing guideline A.A.Haghdoost

Definition

Clinical practice guidelines are recommendations for clinicians

and consumers about optimal and appropriate care for specific

clinical situations


When one needs a guideline

Institute of Medicine (IOM) criteria – clinical practice guidelines are useful when:

– the problem is common or expensive– there is great variation in practice patterns– there is enough scientific evidence to determine

appropriate and optimal care(IOM ,

1992)


Developing methods

Single author - expert opinion

Single author - systematic literature review

Consensus panel using expert opinion only

Consensus panel using evidenced-based approach (AHCPR methodology)


Recommendation sources

Practice

Recommendations

Education

Recommendations

Organization

& Policy

Recommendations


EBM guideline

“Systematically developed statements (based on best available evidence) to assist practitioner and patient decisions about appropriate health care for specific clinical (practice) circumstances”

(Field & Lohr, 1990)


Formal or informal guidelines are the basis for all clinical practice

Basis for most clinical decisions

Foundation of clinical teaching

Mental short-cuts and memory aids for common or complex problems

Primary method to evaluate care patterns and monitor standards of care


Types of recommendations

clinical assessment / treatment – management of cardiac arrest (ACLS)

risk assessment / prevention – drugs to use in pregnancy (ACOG)

administrative – insurance pre-approval for surgery


Functions(1)

Improve patient care

Reduce variation in care

Transfer research evidence into practice

Promote nursing knowledge base

Assist with clinical decision making

Identify gaps in research

Stop interventions that have little effect or cause harm

Reduce cost


Functions(2)

Improving physician practice– increase effectiveness / decrease harms

(better clinical outcomes / cost-effectiveness)

Increasing consumer knowledge – understand potential benefits / harms

Building quality into healthcare systems– using practice guidelines, quality indicators

Guiding government / employer policies– guide programs / policies on healthcare


Target groupsPractitioners in different scientific levels

Patients and their relatives

Community

Health policy makers

Organizations such as insurance companies


Types of evidences for users

Primary literature– Original research

Secondary literature – Systematic reviews, Meta analyses

Translation (tertiary) literature– Guidelines, protocols, care plans


Internet sources

CDC Recommendations:– http://www2.cdc.gov/mmwr/mmwr_rr.html

American Academy of Neurology– Practice Advisories, Practice Parameters,

Therapeutic and Technology Assessments, Credentialing Guidelines, Ethics Statements and Other AAN Position Statements

• http://www.aan.com/public/practiceguidelines/list.htm


Internet sources

American Academy of Pediatrics– Policy Statements

• http://www.aap.org/policy/pprgtoc.cfm

– Clinical Guidelines• http://www.aap.org/policy/paramtoc.html

American College of Cardiology– http://www.acc.org/clinical/guidelines/index.html


Internet sources

American Diabetes Association– Clinical Practice Recommendations– http://www.diabetes.org/DiabetesCare/

Supplement199/default.asp

Canadian Medical Association - CPG Infobase– http://www.cma.ca/cpgs/index.htm– Search engine– Lists by category, title, titles by developer– Recent additions


American Diabetes Association


National Guideline Clearinghousehttp://www.guideline.gov/index.asp


NICE organization in UKwww.nice.org.uk


NICE organization in UK/public health

http://www.nice.org.uk/page.aspx?o=home


NICE organization in UK /clinicalhttp://www.publichealth.nice.org.uk/page.aspx?o=home


Sign organization in Scotland http://www.sign.ac.uk


Finding guidelines in Medline

Indexed in the “Publication Type” [PT] field (most accurate)– Practice Guideline– Guideline

– diabetes mellitus AND practice guideline[pt]


Pubmed


Implementation

Evaluation

Review

DevelopmentDissemination

Guidelines

Developing steps

Pilot studyPilot study

revisionrevision

stakeholdersstakeholders Patients andPatients andcommunitycommunity


Revision

Guidelines should be evaluated at least once every three years, although in subject areas that are prone to rapid change this may need to occur more frequently.


Steps

Define clinical question to be answered (for a specific clinical situation)

Find best scientific evidence relevant to the specific clinical question (using systematic methods)

Rely on best evidence to guide clinical decision-making


Finding the best evidences

Find best scientific evidence that is applicable to the specific clinical situation – individual patient’s clinical situation– program or policy decision

Use evidence to guide decision-making– does the likelihood of benefit outweigh likelihood

of harm enough to justify the cost?– same question applies to individual and society


Developing steps

define clinical questions of interest

develop summary of evidence on:– clinical efficacy (potential benefits)

– potential harms / projected costs

weigh likelihood of benefit versus likelihood of harms, and consider costs

develop finding / recommendation statements

document all aspects of the process


Strength of evidence ratings for guideline recommendations(1)

A = Strong research based evidence– multiple relevant, high quality studies

B = Moderate research based evidence– one relevant, high quality study

C = Limited research based evidence– one adequate study, somewhat relevant

D = Panel opinion – based on information not meeting criteria for A-C


Strength of evidence ratings for guideline recommendations(2)

Ia Meta-analysis or systematic review of randomized control trials

Ib At least one randomized controlled trial

IIa At least one well-designed controlled study without randomization.

IIb At least one other type of well-designed quasi-exp. study without randomization

III Well-designed non-exp. descriptive studies

IV Expert committee reports or opinions and/or clinical experiences of respected authorities


Guideline and medical education

Background questions – general knowledge about a disorder– Look for info in Reference sources: UpToDate,

MDConsult, MICROMEDEX, etc.

Foreground questions – specific knowledge about managing a patient or disorder– Apply EBP techniques, use MEDLINE and other

EBP resources


Guideline and medical practice

BestEvidence

ClinicalExpertise

The Patient

EBP!

Clinically relevant research,

the literature

Practitioner’s knowledge

& experience

Individual’s characteristics & values


Guideline and health related organizations

Health ministry– developing or ordering?– raising funds– implementing– distributing

Medical Universities– Developing– Adding evidence– Criticizing and evaluation– Educating students

Legal system– Justice based on the guidelines

OrganizationsOrderingRaising fundsimplementing


Do we need a special organization to develop guidelines?

Yes, even if we do not need to develop Iranian guidelines, because at least we need

1. To prioritize our needs

2. To find the best available recommendations around the world for each topics

3. To develop our methodology

4. To ……

developing a guideline the ebm workshop a.a.haghdoost, md; phd of epidemiology [email protected]

Documents

practice guidelinept

healthcare slide

surgery slide

cost slide

clinical guidelines

clinical practice basis

uk clinical http

practice patterns