www.wspg.org.ukWest of Scotland Pain Group

www.nbpa.org.ukNorth British Pain

Association

GuidelinesWhat difference do they make?

a Dutch perspective

Raymond Ostelo, PhD, PT

EMGO Institute, VU University Medical CentreInstitute for Health Sciences, VU University

Acknowledgement: Maurits van Tulder, Arno Engers

Content

• Development of evidence based guidelines

• Implementing evidence based guidelines

• Some food for thought /challenges for the future

Why (on earth) do we need guidelines?

Many myths

Evidence based practice

Sackett et al. EBM, Churchill Livingstone, 1997

Conscientious, explicit and judicious use of

current best evidence in making decisions

about care of individual patients

Problem

• The evidence explosion• No individual care provider can be up to date

anymore

Need for systematic reviews

• Systematic

• Transparent

• Reproducible state-of-the-art summaries

Clinical guidelines

• Systematically developed statements to assist

practitioner and patient decisions about

appropriate health care

• Recommendations

• No protocols, no ‘law’

Development and Implementation Cycle

of

Guidelines

ImplementingEvidence

Building Evidence

SystematicalLiterature studies

Clinical guidelines

study the optimal implementation strategies

Audit / monitoring

Study the effect ofimplementation

define health care problem

Experimental studies Observational studiesEconomical evaluation

ImplementingEvidence

Building Evidence

SystematicalLiterature studies

Clinical guidelines

study the optimal implementation strategies

Audit / monitoring

Study the effect ofimplementation

Low Back Problem

Experimental studies Observational studiesEconomical evaluation

ImplementingEvidence

Building Evidence

SystematicalLiterature studies

Clinical guidelines

study the optimal implementation strategies

Audit / monitoring

Study the effect ofimplementation

Low Back Problem

RCTs on effectiveness & Cost effectiveness

ImplementingEvidence

Building Evidence

Sufficient number of systematic (or structured) reviews

Clinical guidelines

study the optimal implementation strategies

Audit / monitoring

Study the effect ofimplementation

Low Back Problem

RCTs on effectiveness & Cost effectiveness

ImplementingEvidence

Sufficient number of systematic (or structured) reviews

Clinical guidelines in the Netherlands:- GP (NHG) guidelines (updated 2004)- Physiotherapy (KNGF) (2001)- Occupational Physicians (NVAB) (1999)- Manual Therapy (NVMT) (2003)- DI Healthcare Imp. (CBO) (2003)- Dutch Health Council (2007)

study the optimal implementation strategies

Audit / monitoring

Study the effect ofimplementation

Low Back Problem

RCTs on effectiveness & Cost effectiveness

Some features of Dutch guidelines

• Mono disciplinary– GP (NHG) guidelines (updated 2004)– Physiotherapy (KNGF) (2001)– Occupational Physicians (NVAB) (1999)– Manual Therapy (NVMT) (2003)

• Multidisciplinary– Dutch Institute Healthcare Improvement (CBO) (2003)– Dutch Health Council (2007)

Some features of Dutch guidelines

• Different methodologies for development– Advisory committee and writing panel – Subcommittees who are responsible for different parts

• Different methodologies for grading the evidence– Strict criteria (e.g. at least 1 good quality systematic

review: ‘level 1’, use phrase ‘it has been shown’ for recommendation

– quality criteria and formulations more loosely used

One feature in common

• All are ‘evidence based’

An intermezzo

Jacob (1785-1863) & Wilhelm (1786-1859) Grimm

An evidence based fairy tale• Once there was… a guideline committee and they defined

the health care problem & searched for the evidence

• then summarized the evidence…

• Then the orthopedists, anesthesiologists & the neurosurgeons did not like the evidence that was not in favor of surgery

• They redefined the health care problem so that they could omit the unfavorable evidence

• They sponsored the guideline so the guideline committee (grudgingly) ‘agreed’

Clinical guidelines for the management of low back pain in primary care:an international comparison

Bart Koes, Maurits van Tulder, Raymond Ostelo,

Kim Burton, Gordon Waddell

Spine 2001; 26: 2504-13.

Sources for differences in recommendations

• health care systems (organisation / financial)

• target population (e.g., GPs, physiotherapists)

Sources for differences in recommendations

• health care systems (organisation / financial)

• target population (e.g., GPs, physiotherapists)

• magnitude of effects

• (in)completeness of evidence

• methods of grading the evidence

• membership of guidelines committees

Clinical Judgment

Evidence based guidelines

Or

Evidence biased guided lies

Implementation

of guidelines

BackgroundRoom for improvement in adhering to the GP guideline

• Referral to physiotherapy for acute LBP pain• Time contingent approach

– medication– bed rest

• Medication– First choice: paracetamol – Second choice: NSAID’s

A multifaceted implementation strategy: aims

• Enhance patient education skills

• Improve referral practices for MT and PT

• Increase the use of written information (pamphlets)

• Increased knowledge of the guideline & relevant

scientific evidence

Why a multifaceted implementation strategy?

• Effective– Educational outreach visits – Multi professional collaboration– Financial interventions– Combined interventions

• Mostly effective– Interactive small group meetings– Mass media campaigns– Reminders– Computerized decision support

(Grol & Grimshaw. Lancet 2003; 362: 1225-30)

• 2 hour Workshop– Discussing relevant issues – Role playing with actor

• Providing pamphlets• Reminder with guidelines of Occup Phys and 2 articles

A multifaceted implementation strategy: training

Results

• A multifaceted intervention slightly modified the management behaviour of GPs in terms of fewer referrals to therapists during follow-up consultations

• It did not lead to more adequate provision of information to patients

Discussion

• GPs in control group also performed well– Is further improvement called for?

• Perhaps focus on situations where adherence to the clinical guidelines is known to be limited

113 PTs 113 PTs randomisrandomiseded

61 61 StandardStandard

DisseminatiDisseminationon

2 drop 2 drop outs outs

11 no 11 no data data

4 drop 4 drop outs outs

11 no 11 no data data

--

--

52 Active52 Active

ImplementaImplementationtion

N=3N=377

N=4N=488

PhysiotherapistsSame as Engers

Inclusion of patients

• New referral for non-specific low back pain

• Exclusion:– Specific low back pain– Pregnancy– Unable to complete questionnaires– No informed consent

Process-oriented outcome measures

• Blinded evaluation of registration forms by 2

researchers using algorithm for 4 key

recommendations:

– Limited number of sessions normal course– Goals focussing on activity and participation– Using active interventions– Giving adequate advise and information

Results process outcomes:% agreement with guidelines

26

79 77

96

42

12

7160

87

30

0

20

40

60

80

100

1 2 3 4 5

implementation

dissemination

1: ≤ 3 sessions 4: adequate information2: adequate goals 5: all recommendations3: active interventions

Results patient-centered outcomes

52 w eken12 w ekenbaseline

Lic

ha

me

lijk

fun

ctio

ne

ren

100

90

80

70

60

50

40

30

20

10

0

interventie

controle

Functional status (QBPDS)

Pain intensity (NRS)

52 w eken12 w ekenbaselineP

ijn

10

9

8

7

6

5

4

3

2

1

0

interventie

controle

Work absenteeism, coping, beliefs similar results

ll l l l l l

Conclusion• The implementation strategy

– slightly improved adherence to the guideline– did not result in additional beneficial effects on patient

outcomes

• Possible explanation: contrast in adherence between the two groups too small

Discussion

• Active strategies for implementing seem (not only from these studies) not beneficial on patient outcomes

• Still there might be other good reasons for using an active strategy to implement guidelines

• In case of similar outcomes, a more transparent health care process or reduction in costs can be reasons to recommend this strategy broadly

Food for thought

• Development

– Think before you leap: www.agreecollaboration.org

– Clinical guidelines are based on systematic reviews

(and/or individual studies) plus clinical expertise

– Saying an guideline is evidence based doesn’t make it

evidence based by itself

– Do weed need mono- or multidisciplinary guidelines?

More food for thought

• Should we adapt existing guidelines or develop

them all over again?

• Implementation of guidelines challenge for the

near future especially for practitioners not

participating in trials

Key messages

Development:

Adhere to guidelines for development

Dissemination should be planned, targeted and evaluated & needs to be supplemented by active implementation strategies

Raymond Ostelo

EMGO Institute, VU University Medical Centre

Institute for Health Sciences, VU University

r.ostelo@vumc.nl