Implementation of Guidelines Bringing guidelines closer to daily practice

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Implementation of Guidelines Bringing guidelines
closer to daily practice

• G. Ollenschläger
• European Conference Information and Quality in
  Health Care
• Krakow, 9 April 2003

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J.Briggs Inst.for Evid.Based NursingMidwifery,
AUS Austrian Forum for Quality in Healthcare
forumQ.at, A Belgian Center for Evidence based
Medicine, B Flemish College of General
Practitioners, B Program in Evidence-based Care,
Cancer Care Ontario, CDN Danish Guidelines
Secretariat, DK Finnish Medical Society Duodecim,
FIN Finnish Office for HTA FINOHTA, FIN French
Nat.Agency for Accred., Eval in Healthcae ANAES,
F French National Federation of Cancer Research
Centres, F German Association of Scientific
Medical Societies AWMF, D Berlin Chamber of
Physicians, D German Agency for Quality in
Medicine ÄZQ, D Royal College of Surgeons in
Ireland RCSI, IRL Italian Evidence-Based Medicine
Group GIMBE, I Regional Health Agency
Emilia-Romagna, I New Zealand Guidelines Group,
NZ Norwegian Directorate for Health and Social
Affairs, NO Portuguese Institute for Quality in
Healthcare, POR Slovene Guidelines Group,
SLO Basque HTA Office OSTEBA, E Josep Laporte
Library Foundation, Barcelona, E Clinical
Epidemiology Center Lausanne , CH Dutch College
of General Practitioners, NL Dutch Institute for
Healthcare Improvement CBO, NL National Institute
for Clinical Excellence NICE, UK Centre for
Reviews Dissemination York, UK Scottish
Intercollegiate Guidelines Network, UK Sowerby
Centre for Health Informatics at Newcastle,
UK Agency for Health Research Quality AHRQ, USA
National Kidney Foundation, USA AGREE
Collaboration, INT World Health Organisation
Geneva WHO, INT

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What is your information strategy in every day
practice ? (Primary Care Physicians)
Dealing with Barriers against CPGs Example User
Rate of Info Tools in Germany
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Implementation of Evidence-based InformationHow
to Overcome Barriers ?
Evidence-based Information (Guidelines,
HTA-Reports, Cochrane-Reports etc)

Knowledge
? ? ? GAP
In- and Out-Patient Care, Health Professionals,
Patients, Health Administration, Politicians
Practice
G.Antes, German Cochrane Center 2002
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Guideline Implementation Key Elements (1)

• Systematic approach to managing the quality of
  health care based upon CPGs is essential.
•  
• Use various dissemination and implementation
  strategies in combinations.
•  
• Consider professional, organisational, financial,
  regulatory incentives and disincentives.
• Consider barriers and facilitators of CPG use at
  both national and local levels (tailored
  implementation).

Council of Europe Rec 13, 2001
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Guideline Implementation Key Elements (2)

•  
• Guidelines must become an essential element in
  the undergraduate and clinical training of health
  care professionals as well as in the continuing
  professional development of health care teams.

Council of Europe Rec 13, 2001
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Effectiveness of Implem.Interventions
Effectiveness Type

• Little or No

• Educational materials only
• Educational lectures

Variable

• Audit and feedback
• Local opinion leaders
• Local consensus process
• Patient-mediated intervent.

Effective

• Educational outreach visits
• Reminders
• Interactive educat. meetings
• Multifaceted interventions

Institut national de santé publique du Québec 2001
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AGREE Instrument DOMAIN 5.APPLICABILITY

• 19. The potential organisational barriers in
  applying the guideline have been discussed.
• 20. The potential costs implications of applying
  the recommendations have been considered.
• 21. The guideline presents key review criteria
  for monitoring and/or audit purposes.

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Factors for Success of CPG Implementation Against
Organisational Barriers Problem based Topic
Selection

• Select CPG topics for important issues in health
  care.
• Base prioritisation on epidemiology of health
  problems, health inequalities, variations in the
  provision and quality of care, emergence of new
  technologies, need for high quality, updated
  information.

Council of Europe Rec 13, 2001
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Factors for Success of CPGs Need Assessment and
Topic Prioritisation

• Example Slovene national CPG on colorectal
  cancer
• Epidemiology

• Slovenia one of the highest incidenc of
  colorect.ca.
• Increase in mortality rates among males.
• 5-year survival shorter than in peer countries.

• Quality of Health Care

• Low detection rate
• local 11, regional 60, advanced 24

Slovene Guidelines Group 2002
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Factors for Success of CPGs Effective
Dissemination and Implementation

• Funding must be considered. The source of support
  must be transparent.
• CPGs should target multiple audiences
  (professionals, patients, and policy makers) and
  be available in suitable formats for different
  groups.
•  
• CPG clearinghouses facilitate the accessibility
  of CPGs.

Council of Europe Rec 13, 2001
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Factors for Success of CPG Implementation Against
Organisational Barriers Diss.Impl. through
Patient Guidelines
Example German Clearinghouse for Patient
Guidelines

• Setting joint priorities for CPG based
  Patient GL topics
• Identification of best available Pat GL
• Joint PGL implem. thru consumer groups and
  physicians

German Guideline Clearinghouse 2002
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Factors for Success of CPG Implementation
Against Organisational Barriers Avoid Top Down
Implementation

• CPGs should not simply be imposed on
  professionals by hospital management or third
  party payers.
• That would result in a standardisation of care
  that leaves insufficient room to the needs of
  each individual patient.
• Neither are guidelines a simple tool for
  allocating scarce resources at the population
  level.

Council of Europe Rec 13, 2001
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Organisational Barriers Example Bottom Up vs.
Top Down Implem. in Germany
German Guideline Clearinghouse 2002
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Success of Internal vs. External CPGs
Internal guidelines External guidelines Authors P
roviders Health care administration Scope Educatio
nal tool Medicolegal instrument Purpose Improvemen
t of Rationalization of health patients
outcome, care, Cost reduction Medical
audit Com- Good Lowpliance (38 positive) (79
negative)
Grilli R, et al. Soc Sci Med 1996431283-1287
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Factors for Success of CPG Implementation Evaluati
on of Guidelines Impact

• Well-planned monitoring of guideline effects is
  essential, and especially the impact of
  guidelines on health outcomes needs further
  development and evaluation.
•  
• Guidelines can include a list of essential
  indicators that can be used for evaluating the
  results of guideline implementation.

Council of Europe Rec 13, 2001
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Development of Quality Measures Many Challenges

• Difficult to develop rigorous quality measures
• Appropriate and available data sources
• Reliability and validity testing is difficult and
  expensive
• Quality measures must be current with CPGs
• Attributes of measures poorly described

J. Slutsky, US Guidelines Clearinghouse, 2002
www.cpg2002.de
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Systematic Develop. of Quality Measures Planning
Development Phases

• Identify
• objectives of quality assessment
• relevant guidelines and procedures
• patient target groups
• relevant CPG recommendations from which quality /
  outcome measures may be derived
• 5. 11. Defin. of measures, tools, procedures,
  pilot test

US Agency for Health Care Research and Quality -
www.ahrq.gov
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Systematic Develop. of Quality Measures
Implementation Phase

• 12. Collect data, check quality of data.
• 13. Compile the results, check for quality
  presentation of results
• 14. Interpret results, perform quality assessment
• 15. Check the results, modify the evaluation tool
  if necessary
• 16. Establish a centre for evaluation and control
• 17. Define measures of quality improvement
• 18. Repeat quality assessment

US Agency for Health Care Research and Quality -
www.ahrq.gov
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ExampleNational quality indicators for
in-patient carein GermanyGeraedts, ISTAHC 2002
Evaluation of Guidelines Impact Selection of CPG
based Quality Measures
Cases with blood transfusion in hysterectomies
Cases with prophylactic antibiotics in breast
cancer surgery
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Key Points for CPGs Acceptance

• Clinical practice guidelines should
• link recommendations with underlying evidences
• deal with every day health care problems
• help professionals in providing best medical
  practice at minimal expenses
• give detailed description of best medical
  practice processes

Grol et al 1998
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Effect of Active Dissemination on Use of
Ante-natal Corticosteroids

• Disseminated 1994
• NIH Consensus
• Conference recommendations
  
• Usual Dissemination
• publication, lectures,
• word-of-mouth
• Active Dissemination
• opinion leaders, presentations,
• chart reminders, organized
• discussions, monitoring
• and feedback
• Active strategy led to
• 33 greater change

Source LC Leviton et al., JAMA 28146, 1999
J. Slutsky, US Guidelines Clearinghouse, 2002
www.cpg2002.de

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The Genealogy of Quality Quality Research to
Quality Care
J. Slutsky, US Guideline Clearinghouse, 2002
www.cpg2002.de
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International Symposium on Clinical Practice
Guidelines

• Networking for Evidence-Based Healthcare

November 14-16 2003 Edinburgh, Scotland