PowerPoint Presentation

Evidence-Based Clinical Practice Guidelines For Staff ofHematology-Oncology UnitKing Khalid University Hospital

2013

PART 1: IntroductionInstructorDr. Yasser Sami Amer, MBBCh, MScPediatrician - HC InformaticianMember, G-I-N Adaptation Working Group/Steering CommitteeCPGs General Coordinator, QMD, CPG Committee,King Saud University HospitalsKKUH/KAUH

Concepts & Definitions

Two Different Approaches to Evidence-Based Practice (EBP)Clinical Practice Guidelines (CPGs)Top-down approach Tell clinicians how to practice Favored by health care systems

Evidence-Based Medicine (EBM)Bottom-up approach Teach clinicians how to find answers Favored by medical educators

EBM definitionThe integration of best research evidence with clinical expertise and patient valuesSackett et al 2000

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What is EBM NOT?What we have always done !;(not old hat or just the same old medical practice; as evidenced in wide practice variation)Cookbook Medicine!EBM specifically advocates for individualized application of evidence to patient care, not forcing patient care to conform to generalized evidenceOnly a cost-cutting trick !;it is intended to guide practitioners to provide the best, not necessarily the cheapest, care.Only RCTs !;(Also with best relevant evidence applicable to the situation in question)

EBM is tracking down the best external evidence from scientific research to answer our clinical question(s)

Definition: (old)Systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances (Institute of Medicine 1990).

Increasing international interest in the development and implementation of CPGs.

Clinical Practice Guidelines (CPGs)

CPGs New DefinitionCPGs 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.Committee on Standards for Developing Trustworthy CPGs (IOM-AHRQ)

WHY do we need CPGs?

Rationale for CPGs

Worldwide concerns about:-Unexplained variations in clinical practiceRising health care costsExponential growth of information

Aim of CPGs:-To facilitate more consistent, effective and efficient practice and improve health outcomes for patients

Evidence-Based CPGsClinical Care GAP

Current Practice

Best Practice

Guidelines

WHO needs CPGs?

Stakeholders

DoctorsNursesDecision makersPatientsPublic

CPGs on the Web

CPGs on the Web

CPGs ProducersSpecialized Onco societies:- National Comprehensive Cancer Network (NCCN) - USAAmerican Society of Clinical Oncology - USAAmerican College of Radiology - USAOncology Nursing Society USACancer Care Ontario CANCancer Council Australia - AUSSaudi Oncology Society - KSA

National CPGs agencies:- NICE - UK SIGN - UK

7 Adapted CPGsTo MENA

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SIGNScottish Intercollegiate Guidelines Networkwww.sign.ac.uk

CPG Producers:National Agencies

CPG Producers:National Agencies

NICENational Institute for Health & Clinical Excellencewww.nice.org.uk

CPG FindersAHRQNational Guideline Clearinghousewww.guidelines.gov

CPG FindersGuidelines International Network (G-I-N)www.g-i-n.net

Org. Member since 2009

Shaikh Bahamdans Research Chair for Evidence-Based Health Care & Knowledge TranslationMember of G-I-N since Oct. 2009Free access to International CPG Library of G-I-N

http://c.ksu.edu.sa/ebhc

http://ebhc.ksu.edu.sa/gin/index.html

CPG FindersPubMedUS National Library of MedicineNational Institutes of Health (NIH)

Some CPGs are only retrievable by Googling them!

The Main CPGs Database websites we start searching:-1- National Guidelines Clearinghouse (NGC):www.guidelines.gov 2- Guidelines International Network (G-I-N) (International Library): www.g-i-n.net3- National Institute of Clinical and Health Excellence (NICE):http://www.nice.org.uk/guidance/4- Scottish Intercollegiate Guidelines Network (SIGN):http://www.sign.ac.uk/guidelines/5- DynaMed database: Evidence-based clinical referencehttps://dynamed.ebscohost.com/6- National Health and Medical Research Council - Australian Government:http://www.nhmrc.gov.au/guidelines-publications7- Google/ Google Scholar:www.google.com

How do we react to guidelines?

CPGs ?

TopicTeamContentSearchFOUNDNOT FOUNDAppraiseDevelopAppraiseAdopt or AdaptImplementEvaluate impact

Adaptation of Clinical Practice GuidelinesThe ADAPTE collaboration is an international collaboration of CPG researchers, developers and implementers. Their main aim is to develop and validate a generic adaptation process that will foster valid and high-quality adapted guidelines as well as the users sense of ownership of the adapted guideline.

Guideline AdaptationIs the systematic approach to the endorsement and/or modification of a guideline(s) produced in one cultural and organizational setting for application in a different context. Adaptation may be used as an alternative to de novo guideline development, e.g., for customizing (an) existing guideline(s) to suit the local context.

http://www.adapte.org/

We identified 3 main ADAPTE steps:-Adaptation Phase

CPG Scope: PIPOH ModelPatient (& disease characteristics)Intervention(s)Professionals (Target users)Outcomes (purpose of the CPGs)Healthcare settings (& context)

= Health/ Clinical/ Key Questions

Evidence PyramidMARCTCohortCase controlCase seriesCase reportExpert opinion

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II

III

IV

ABCLevels of EvidenceGrades of Recommendations

How to assess of the quality of any CPG ?

Assess guideline quality

ADAPTE TOOL 9 AGREE II Instrument

23 items in 6 domains 7 point response scale Domain scores Recommendations

Considerations before a CPG Assessment

23 Items in 6 DomainsUSERS MANUAL page 7

DOMAINSNo. of Items1Scope & Purpose32Stakeholder Involvement33Rigour of Development84Clarity & Presentation45Applicability36Editorial Independence2

7. Systematic methods for E search8. Selection Criteria of E9. Strengths & Limitations of E10. Methods of Rs 11. Benefits , side effect and risks in Rs12. Evidence Links (Gs of Rs LoE)13. External Review 14. Update Procedure

DOMAIN 3. RIGOUR OF DEVELOPMENTMethods, literature search strategy & appendices+ inclusion/ exclusion criteria+ Evidence tables, clinical evidence, evidence description (results), evidence interpretation (discussion)Methods, CPG Development process same sections+ Rs, Key Evidence+ acknowledgements+ CPG update, date of CPG

AGREE Enterprise website http://www.agreetrust.org/

CPGs: 1 (or 2) documentsFIRST (Clinicians Version)Accessible from ALL points-of-care for the hospital staff:Details of evidence-based recommendations for management (with only references to the other document)

SECOND:(Methodologists Version) ; Accessible from Libraries of e.g. Department, College of Medicine, CPG Committee, QMD, Authorship group,etc. (Reference for Replication & Documentation)Detailed description of the CPG Adaptation process with ALL relevant data.

Dissemination & ImplementationNothing could be more frustrating than producing a CPG that is then ignored by not being disseminated nor implemented

Dissemination of CPGs

External Review Full CPGs documents published on websitesImplementation tools will also be published: examples for choice:-Quick Reference Guide (Summary Key Rs)Clinical Algorithms (decision tree)Clinical pathways (Integrated care pathways)Order SetsPatient Information (Education Guide) ArabicClinical Audit ToolCPOE (Computerized Physician Order Entrty) = e-SIHI (New HIS)ICD 10 Codes

If CPGs are to have a positive impact on patient care outcomes they must be implemented and incorporated into everyday clinical practice

The identification of any barriers to implementation, and strategies for overcoming them, will form an essential part of discussions at CPGs Subcommittee/ Adaptation Group meetings

Implementing Guidelines

Hematology-OncologyClinical Practice Guidelines SubcommitteeMultidisciplinary !TEAM WORK

TEAMTOGETHEREVERYONEACHIEVESMORE

Participating/ promoting EBCPGs/ EBHC

WIN WIN !MYSELFMY PATIENTS/ CLIENTSMY DEPARTMENTMY HOSPITAL

MYSELFWIN WIN !Participating/ promoting EBCPGs/ EBHCImprove our Life-long learning & Information Mastery SkillsImprove our informed Clinical DecisionsImprove our patients (customers) outcomesImprove our UG/ PG Teaching toolsAuthorship of Publication (CPG Book/ Article)Organizational Member in G-I-NKSUHs EBCPGs ChampionsHonoraria (Incentives),and more!

Dr. Yasser Sami AmerMSc Pediatrics, MSc HC InformaticsCPGs G. Coordinator, QMD, CPGC, KKUH/ KAUH