Indicators and Guidelines Companions on the Quality Path

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Indicators and GuidelinesCompanions on the
Quality Path
Günter Ollenschläger Joint CoE / ESQH / G-I-N
Workshop 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 are CPGs ?

• ...systematically developed statements
• to assist practitioner
• and patient decisions
• about appropriate health care
• for specific clinical circumstances.
• Institute of Medicine
• Clinical Practice Guidelines Directions for a
  New Program. (1990)
• Guidelines for Clinical Practice From
  Development to Use. (1992)
• Setting Priorities for Clinical Practice
  Guidelines. (1995)
• Washington DC National Academy Press, 1995.

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Guidelines on Best Medical PracticesCoE
Recommendations 2001

• Aims of Guidelines
• Topic selection
• Development
• Dissemination
• Implementation
• Evaluation
• Updating

Council of Europe Rec. No. R (01) 13
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Aims and Functions of CPGs
Guidelines are tools for
linking research, education and practice making
decisions more rational, transparent
supporting quality improvement in health care
delivery

• promoting effective consumer-oriented health
  outcomes
• increasing efficiency and contributing to coast
  containment

Council of Europe Rec. No. R (01) 13
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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

• 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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Dimensions of Quality Improvement Systems
Procedures and Processes

• Identify quality problems
• Collect data on care provision
• Use evidence-based guidelines
• Implement necessary changes
• Measure the impact of changes
• Exploit best practices

CoE Rec 13, 2001
Council of Europe Rec 17, 1997
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Key Points for CPGs Acceptance

• Clinical practice guidelines should
• link recommendations with underlying evidences
• deal with every day problems in health care
• 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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Problems of Guidelines WorldwideQuality Deficits

• 1. Only few mention recommendations' evidences
• 2. Most of them without information on
  development process, sponsorship /
  accountability, implementation tools
• 3. Cost-benefit-questions often excluded as
  topics
• 4. Conflicting guidelines on relevant topics
• 5. Most of them academic recomm.(non-compliance
  in amb.care)

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International CPG Quality Activities
Promotion of intern. networking between
organisations, research institutions,
clearinghouses and other agencies producing
evidence-based medical information.

• Agree Collaboration
• (Biomed 2, EU)
• Council of Europe CPG Recommend.
• G-I-N

• Research, training on high quality CPG devel. /
  use
• Policy paper on CPG standards
• CPG information, dissemination, networking

Council of Europe Rec. No. R (01) 13
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High Quality Guideline Development
CPGs should be produced by multiprofessional
groups in a systematic, independent and
transparent fashion, using appropriate quality
criteria.
Desirable attributes of Guidelines (IOM 1990)

• Validity
• Strength of evidence
• Estimated outcomes
• Reliability / reproducibility
• Clinical applicability

• Clinical flexibility
• Clarity
• Multidisciplinary process
• Scheduled review
• Documentation

Council of Europe Rec. No. R (01) 13
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Principles of Systematic CPG Development
Example Slovene Guideline Programme

• Systematic, transparent, fully documented
  development
• Multidisciplinary involvement at all stages
• Recommendations on the best available evidence
• CPGs meet current international standards
• Based on existing good quality CPGs, updated,
  adapted for use in Slovenia
• Implementation issues considered

Slovene Guidelines Group 2002
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Slovene Guidelines Manual Version 2.1 November
2002
Slovene Guidelines Group 2002
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Multidisciplinary CPG Development Group Example
Slovenian Colorectal Cancer CPG Group

• Gastroenterology
• Surgery
• Oncology chemotherapy radiotherapy
• General practice
• Epidemiology
• Genetics
• Pathology
• Radiology
• Palliative care
• Pharmacy
• Nursing
• Healthcare management
• Health economics
• Patients

Slovene Guidelines Group 2002
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Slovene Guidelines Manual Version 2.1 November
2002
Slovene Guidelines Group 2002
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Remit
Key Questions
Literature Search
Evidence Table
Evidence Table
Evidence Table
Considered Judgement form
Considered Judgement form
Considered Judgement form
Guideline recommendations
J. Miller, SIGN 2002 www.cpg2002.de
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Slovenian Guidelines Manual Version 2.1 November
2002
Slovene Guidelines Group 2002
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Consultation and Peer Review

• Draft guideline available at
• www2.gov.si/hsmp/hsmp.nsf/Komponenta1/Delovna
  skupina za podkomponenta 1.3
• Please send comments by e-mail to
• serge.heijnen_at_gov.si
• Closing date for comments
• 13 December 2002

Slovene Guidelines Group 2002
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Slovenian Guidelines Manual Version 2.1 November
2002
Slovene Guidelines Group 2002
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Systematic Guideline Production and Use
Ethical, economic and legal environment
Topic selection
Development
Dissemination
Review
Patients Professionals Policy makers
Evaluation
Implementation
Monitoring
Resources
Optimal health care
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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CPG based Quality Measures Example Scottish
Standards Colorectal Carcinoma
Standard No.
4. Communication and Information Sharing
Informed decision making 5. Audit Continuous
collection of SIGN Collorectal Carcinoma Core
Data Set, Participation in national data quality
assurance programme 6. Clinical trials
Recording of patients, informed consent, ethical
committee 7. Assessment and care planning
Individual, documented care plan 8. Waiting
times diagnosis/ treatment radiother.booking/sta
rt, surgery/chemotherapy
B. Steele, Dundee 2002, www.sign.ac.uk
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CPG based Quality Measures Example Scottish
Standards Colorectal Carcinoma
met 11 / 28 major. where acc. 20 / 28 14 / 28 12
/ 28 21 / 28 28 / 28
not met 17 / 28 rare 8 / 28 7 / 28 - 7 / 28 -
not assessable - too often - 7 / 28 16 / 28 - -
Standard Referal Preoperative care Pathology
Report Adj. Chem. (gt 15 Pat.) Radiotherapy Nursin
g Patient Information
Reviews of 28 Hospitals
B. Steele, Dundee 2002, www.sign.ac.uk
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Main Aim of Guidelines Support and Promotion of
Good Clinical Practice

• Identify quality problems
• Collect data on care provision
• Use evidence-based guidelines
• Implement necessary changes
• Measure the impact of changes
• Exploit best practices

CoE Rec 13, 2001
Council of Europe Rec 17, 1997
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International Symposium on Clinical Practice
Guidelines

• Networking for Evidence-Based Healthcare

November 14-16 2003 Edinburgh, Scotland