guidelines in the united kingdom and how they are utilised dr paul stevens kent kidney care centre...
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Guidelines in the United Guidelines in the United Kingdom and How They Are Kingdom and How They Are
UtilisedUtilised
Dr Paul Stevens
Kent Kidney Care Centre
United Kingdom
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Lord Darzi: Next Stage Review
Word or phrase Number of mentions
Quality 359
Measures 23
Quality standards 4
Quality measures 3
Comparable measures 3
Quality metrics 2
Quality standards (set by NICE) 2
Clinical guidelines 0
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Sustainability in the NHS – Guideline recycling
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Talk Outline
• Guidelines: Plato or Playdough?
• History
• Methodology
• Implementation
• Closing the gap
• Guideline excellence
• Generalisability
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Playdough (Play-Doh)
• Originally a putty-like wallpaper cleaner
• Named Play-Doh in 1955• Exported to Europe 1964• Play-Doh compound is
non-toxic, non-irritating & non-allergenic
Highly cost effective!
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I think we’ll strip clinicians of their clinical freedom and determine majority views about practising medicine
Clinical guidelines help health professionals in their work, they do not replace their knowledge and skills
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Guideline
NDTAJKD
JASN
CJASN
NEJM
Cochrane
PubMed
HTA
BNF
KI
JAMA
BMJ
Medline
DARE
DUETs
SIGN
Annals
Archives
AJN
Nephron
NDT +
Multiple Sources of Information
Guideline process sorts, sifts, assesses quality and prioritises
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“NICE: A panacea for the NHS? No, but it should be useful for managing the introduction of new technologies”
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“NICE may prove to be one of Britain’s greatest cultural exports, along with Shakespeare, Newtonian physics, the Beatles, Harry Potter, and the Teletubbies”
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NICE Guidance in Kidney Disease
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UK Renal Association History
“Thus when in October 1959 the Executive Committee received a letter from Dr [Frank] Parsons suggesting that a meeting should be devoted to a symposium on the artificial kidney. The Committee rejected this proposal.”
“A striking feature of the programmes of the Association during the 1960s is that still only 8 papers relating to dialysis were presented”
“papers on subjects relating to dialysis remained rare at the Association meetings for another decade more”
http://www.renal.org/pages/pages/the-association/history.php
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Renal Association Memorial
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UK Renal Association History
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UK Renal AssociationClinical Practice Guidelines 4th Edition
Module DateReview
Due
Chronic kidney disease - led by Charlie Tomson, Maarten Taal
10/4/2007 2009
Complications - (CV disease, bone disease, anaemia, nutrition) - led by Mike Cassidy, Donald Richardson, Colin Jones
11/12/2007 2009
Blood-borne viruses – led by Colin Geddes 26/2/2009 -
Haemodialysis - led by Robert Mactier 26/3/2007 2009
Peritoneal dialysis - led by Simon Davies 15/5/2007 2009
Peritoneal access – led by Martin Wilkie 26/2/2009 -
Assessment for transplantation - led by Chris Dudley, Paul Harden
8/4/2008 2010
Acute Renal Failure (Acute Kidney Injury) - led by Paul Stevens, Andrew Davenport
8/4/2008 2010
http://www.renal.org/pages/pages/guidelines/current.php
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UK Renal AssociationClinical Practice Guidelines 5th Edition
• Detection and management of CKD• Cardiovascular disease in CKD• Mineral metabolism in CKD• Nutrition in CKD• Anaemia in CKD• Infection control in the renal unit• Planning for renal replacement
therapy or conservative management in CKD
• Haemodialysis• Vascular access• Peritoneal dialysis• Peritoneal access• Evaluation of the kidney
transplant candidate• Medical management of the
kidney transplant recipient• Acute kidney injury
http://www.renal.org/pages/pages/guidelines/future.php
Due 2009/2010
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• Key attributes for clinical practise guidelines
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AGREE
• Scope and process – clearly defined
• Stakeholder engagement policy
• Rigorous development process –including systematic searching, inclusion/exclusion criteria etc
• Recommendations clearly presented
• Applicability considered
• Reliable – absence of bias
www.agreecollaboration.org
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The Importance
of Evidence
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Copyright ©2004 American Society of Nephrology
Strippoli, G. F. M. et al. J Am Soc Nephrol 2004;15:411-419
Figure 1. Number of randomized controlled trials (RCT) published in nephrology and 12 other specialties of internal medicine from 1966 to 2002
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Pubmed Articles: Human Kidney Disease 1991 - 2008
Publication Year
Nu
mb
er
29 109 252
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GRADE System
• Quality of evidence– High– Moderate– Low– Very low
• Strength of recommendation– Strong– Weak
Guyatt et al. BMJ 2008;336;924-926
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• Individuals who insist that all interventions need to be validated by a randomised controlled trial need to come down to earth with a bump
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Guideline Development Group
• Dr David Halpin, Chair • Dr Paul Stevens, Clinical
Advisor • Dr Eric Will, BRS• Professor Alison MacLeod
Cochrane Renal Group• Dr Mick Kumwenda, BRS• Dr Jonathan Evans, BAPN• Dr Paul Roderick, Public Health • Dr Penny Ackland GP • Dr Samir Agrawal,
Haematologist• Dr Shelagh O’Riordan, BGS• Dr Stephen Thomas, RCP• Mr Robert Dunn, NKF• Ms Christine Howard, NKF
• Ms Alison Roche, ANSA • Ms Carol Anderson, ANSA • Ms Karen Jenkins, RCN• Mr Robert Bradley, Renal
Pharmacist • Dr Nyokabi Musila, NCC-CC• Ms Debbie Nicholl Health
Economist• Mrs Alison Richards, NCC-CC• Mrs Bernadette Ford, NCC-CC• Dr Jane Fisher, NCC-CC• Mr Rob Grant, NCC-CCPlus• Ms Jane Alderdice, Renal
Dietitian• Project Executive
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No Industry/Organisational Influence
• Moynihan R. Who pays for pizza? Redefining the relationships between doctors and drug companies. BMJ 2003;326:1189-1192
• Blumenthal D. Doctors and drug companies. N Engl J Med 2004;351:1885-1890
• Kassirer JP. How drug lobbyists influence doctors. Boston Globe. February 13, 2006:B9
• Campbell E et al. A National Survey of Physician–Industry Relationships. N Engl J Med 2007 356: 1742-1750
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Review by Others
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AGREE or Disagree?
AGREE Criteria NICE RA
Scope and purpose +++ +--
Stakeholder involvement +++- ++--
Rigour of development +++++++ ++++---
Clarity and presentation ++++ ++++
Applicability ++-- +--
Editorial independence ++ ++
20/23 14/23
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So……Plato or Play-Doh?
• Plato aspects of guidelines unfetter your chains, set you free from blindness, foolishness, closed-mindedness, narrow-mindedness, and pride
• ‘Play-Doh’ aspects of guidelines afford you the creativity that is an essential part of early educational development and give you a new happiness from your discoveries
“We have the science of discovery but what we need is the science of implementation”
Lord Darzi
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Implementation and Adherence
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Implementation
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MotivationAwareness and knowledge
PracticalitiesSkills
Acceptance and beliefs
Educational materials
Meetings
Outreach visits
Reminder systems
Opinion leaders
Patient mediated strategies
Clinical audit & feedback
Overcoming Barriers
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Implementation
• Raised awareness
• Planning change
• Partial implementation in one area
• Full implementation in one area
• Full implementation across all areas
• Overcoming Barriers
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Principles of Implementation
• Board support and clear leadership
• Provision of a dedicated resource
• Support from a multidisciplinary team
• Systematic approach to financial planning
• Systematic approach to implementing guidance
• Process to evaluate uptake and feedback.
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Process for Implementing Guidance
Set up review
process
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“Yes, but as part of an integrated care strategy”
Should We Follow Guidelines?
“We’ll think about it.”
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The Renal NSF: Part 2
• Quality requirement 1: Prevention and early detection of chronic kidney disease (CKD)
• Quality requirement 2: Minimising the progression and consequences of CKD
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April Fools Day 2006
eGFR reporting
QOF
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Quality and Outcomes Framework
• The QOF is intended to measure, encourage and support clinical care and a patient experience which is constantly improving
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Renal Indicators in the QOF
Indicator 1 Register of patients aged 18 years and over with CKD Stage 3-5
Indicator 2 % of patients on the CKD register with a record of blood pressure in the previous 15 months
Indicator 3 % of patients on the CKD register with a BP ≤140/85
Indicator 5 % of patients on the CKD register with hypertension and proteinuria who are treated with an ACEI/ARB
Indicator 6 % of patients on the CKD register with measurement of ACR in last 15 months
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Guideline Referral Recommendations
• Stage 4 or 5 CKD ± diabetes
• High levels of proteinuria (ACR ≥70 mg/mmol)
• Proteinuria (ACR ≥30 mg/mmol) together with haematuria
• Rapidly declining GFR
• Refractory hypertension
• Suspected rare or genetic causes of CKD
• Suspected renal artery stenosis
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020406080
100120140160180200
Kent Monthly New Referrals 2003-2008
August 03 – March 2006 April 2006 – August 2008
Hobbs et al, Unpublished data
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Why Identify Chronic Kidney Disease?
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Kent New Referrals by CKD Stage
Hobbs et al, Unpublished data
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Late Referral: UK Renal Registry Data
%
Year
UK Renal Registry Report 2008
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The Renal NSF: Part 1
1. Patient centred service
2. Preparation & choice
3. Elective dialysis access surgery
4. Dialysis
5. Transplantation
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What is Audit?
• Awfully• Uninteresting• Deadly Dull• Immensely• Tedious
• Amazingly• Underutilised• Driver for• Improvement in• Treatment
Charlie Tomson, with thanks
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Using National Audits to Drive Local Improvement
• If you cannot measure it, you cannot improve it – Lord Kelvin, 1824-1907
• Stages of facing reality:– “The data are wrong”– “The data are right, but it’s not a problem”– “The data are right; it is a problem; but it is not
my problem”– “I accept the burden of improvement”
Berwick D. Qual Saf Health Care 2003;12(S1):2-6
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Shifting the Population MeanP
op
ula
tio
n n
um
ber
s
Decreasing mortality risk →
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Audit in Nephrology
• No shortage of problems
• No shortage of audit standards/criteria
• Highly computerised
• Many numerical measures e.g. Hb, URR, PO4, % catheter use
• Very little evidence of implementation of change
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%of Patients With URR >65
UK Renal Registry Report 2008
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Unit Performance is a Stable Characteristic
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The Centre Effect in RRT
• UKRR observes marked, stable (year on year) centre variation in– % URR >65– % Hb between 10.5 and 12.5 g/dL– % SBP < 140 mm Hg– Survival
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Multidisciplinary learning session BRS, 12th June 2007
“All teach, all learn”
Learning session – that’s NOW!
Identify best-performing Units for each topic area; develop ‘change package’
Data from UKRR and other national audits
Multi-specialty improvement teams
Web-based social network allowing sharing of protocols, ideas, tests of change, RESULTS
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Lessons learnt
• High-performing centres may not know what they do that others don’t
• Fostering collaboration requires continued input and a purpose-built website
• Teaching Quality Improvement methodology probably takes more than 60 minutes
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Understanding the ‘Centre Effect’
• Differences in outcomes between centres that cannot be attributed to differences in case mix
• Structure + Process = Outcome• Requires detailed understanding of how centres
organise and deliver treatment– Qualitative research to identify candidate practice
patterns– Quantitative research to find out which practice
patterns are associated with the best outcomes
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Door to Balloon Time (DTBT)
• Qualitative study of common approaches in hospitals that achieve rapid DTBT
• Quantitative study of 28 candidate practices: 6 strategies statistically significant:– ER physicians activate cath lab– Single call to switchboard to activate cath lab– Activate cath lab while patient en route to hospital– Expect staff to arrive within 20min of being paged– Attending cardiologist always on site– Real-time data feedback to ER and cath lab staff
Bradley JACC 2005; 46; 1236; Bradley NEJM 2006; 355; 2308
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Closing the Gap: Aims
• Create quality improvement programmes in renal centres in England, Wales and Northern Ireland
• Maximise compliance with Renal Association Standards
• Devise a quality improvement model which is sustainable and transferable to similar organisations in the UK
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Improving on League TablesPercentage of haemodialysis patients with serum phosphate
<1.8mmol/L
35
45
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65
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0 P
rest
n 5
Car
lis 4
Eng
land
2 N
Ire
land
12 W
ales
5 E
,W&
NI
Centre
Pe
rce
nta
ge
of
pa
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ts
Upper 95% confidence interval
% with P04 < 1.8mmol/L
Lower 95% confidence intervalN = 17,319
Median rank for percentage of HD patients with phosphate<1.8mmol/L
0
10
20
30
40
50
Centre
Ra
nk
Upper 95%Confidence intervalMedian rank
Lower 95%Confidence interval
Standard ‘caterpillar’ plot
Monte Carlo analysis using 5000 samples from the distribution from each centre: median rank of each centre with confidence intervals
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Summary (1): Evidence Into Practice
1. Summarise the evidence
2. Identify local barriers to implementation
3. Measure performance
4. Ensure all patients receive the intervention
Pronovost et al. BMJ 2008;337:a1714
Johns Hopkins evidence into practice model
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Summary (2)
• High quality audit by direct extraction of data from clinical electronic records is feasible and generates tension for change
• Learning from high performance requires detailed understanding of structure and processes in high-performing centres
• Near-real-time statistical process control charts likely to stimulate and reward QI
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8 strategies for Achieving Change
1. Make the desired action the default2. Steal ideas shamelessly3. Actively encourage collaboration4. Involve the people who do the work5. Spread successful new ideas rapidly6. Align financial incentives to quality7. Use patient power8. Raise expectations amongst
commissioners
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