A COMMON APPROACH

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Developing Evidence-Based Guidelines for Health
Protection - An overview of the process -


A COMMON APPROACH ALEX SANCHEZ-VIVAR
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Moriarty Everything I have to say has already
crossed your mind. Sherlock Probably my
answer has crossed yours.
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Presentation Overview

• Intro the Health Protection Network (HPN)
• Why does Evidence-Based Practice matter to us?
• Rationale background
• 3. A systematic approach to produce guidance for
  HP in Scotland
• Development of evidence-based guidelines

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1. The Health Protection Network (HPN) in
Scotland
The Health Protection Network (HPN) is a network
of existing professional organisations and
networks in the health protection community
across Scotland. It aims to promote, sustain,
and coordinate good practice. The HPN does this
by adopting, promoting and disseminating a
systematic approach to develop evidence-based
guidelines, as well as by ensuring an appropriate
workforce development plan is in place and
complied with.
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• MEMBERSHIP
• Scottish CPHM (CD/EH) Group
• Health Protection Nurses Specialist (Scotland)
  Network
• (HPNS)
• Health Protection Scotland (HPS)
• Infection Prevention Society (IPS)
• The Royal Environmental Health Institute of
  Scotland
• (REHIS)
• Scottish Infection Research Network (SIRN)
• Scottish Microbiology Virology Network (SMVN)
  and the
• Scottish Clinical Virology Consultants Group
  (SCVG)
• Scottish Public Health Network (ScotPHN)
• Society of Chief Officers of Environmental
  Health (SoCOEH)
• Health Protection Education Programme (HPS/NES)
• Public Representative

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• Why does evidence-based practice matter to us?

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Rise of Evidence-Based Medicine

• First described in 1992
• A new approach to teaching medicine
• A revolution in medical practice
• Other evidence-based approaches ethics,
  psychotherapy, occupational therapy, dentistry,
  nursing, and librarianship

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Factors Driving EBM

• Overwhelming size of the literature
• Inadequacy of textbooks
• Difficulty synthesizing evidence and translating
  into practice
• Increased number of RCTs
• Available computerized databases
• Reproducible evidence strategies

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Definition of EBM

• The integration of best research evidence with
  clinical expertise and patient values.

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Steps of EBM

• Convert the need for info. into an answerable
  question
• Track down the best evidence
• Critically appraise that evidence
• Integrate the appraisal with ones clinical
  expertise and the individual patient
• Evaluate

Sackett DL. EBM how to practice and teach EBM.
Churchill Livingstone 2000
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Critique of EBM

• De-emphasizes patient values
• Doesnt account for individual variation
• Devalues clinical judgment
• Leads to therapeutic nihilism

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Development of EBPH

• Jenicek (1997) published a review discussing
  epidemiology, EBM, EBPH
• Epidemiology described as the foundation of both
  EBM and EBPH
• EBPH unique in using complex interventions with
  multiple community and societal issues

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Definition of EBPH (1)

• EBPH is the conscientious, explicit, and
  judicious use of current best evidence in making
  decisions about the care of communities and
  populations in the domain of health protection,
  disease prevention, health maintenance and
  improvement.
• Jenicek (1997)

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• Strong evidence supports that
• teaching is not effective on Friday afternoons

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Interpretation of communications

• Trust? source
• Evidence Identified and synthesised?
• Recommendations link with the evidence?
• Validation ? improve practice? ? implementation

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Health Care / Medical Sciences Literature -
Half of what we are taught as medical students
will in ten years have been shown to be wrong.
The trouble is, none of teachers knows which
half. Dr Sydney Burrell, Dean of Harvard
Medical School (2000)
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Concepts
Good Practice GUIDELINES Systematically
developed statements to assist practitioner and
patient (public) decisions about appropriate
public health interventions
for specific circumstances Derived from
Institute of Medicine Committee to Advise the
Public Health Service on Clinical Practice
Guidelines. Clinical Practice Guidelines
Directions for a new program. Washington DC
National Academy Press, 1990.
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Concepts
What makes a good guideline?

• Should provide extensive, critical and
  well-balanced information on the benefits and
  limitations of various interventions so that the
  practitioner can carefully judge individual
  cases
• Derived from
• Subcommittee of WHO. Summary of the 1993 WHO.
• BMJ 1993 307 1541-1546

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Concepts
Guidelines Purpose

• To make explicit recommendations with a definite
  intent to influence what physicians do
• Derived from
• Hayward RSA, Wilson MC, Tunis SR, Bass EB,
  Guyatt G, for the Evidence-Based Medicine
  Working Group. Users guides to the Medical
  Literature. VIII How to use Clinical Practice
  Guidelines. A Are the Recommendations Valid?
  JAMA 1995lt 274gt 570-574

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Criteria
What makes a good guideline?

• Valid
• Reproducible
• Cost-effective
• Representative / multidisciplinary
• Clinically applicable
• Flexible
• Clear
• Reviewable
• Amenable to clinical audit

NHS Executive. Clinical Guidelines. Leeds NHSE,
1996
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Potential benefits of Good Practice Guidelines

• For the public / patients
• For healthcare professionals
• For healthcare systems

Adapted from Woolf SH et al. Potential benefits,
limitations and harms of clinical guidelines. BMJ
1999 318 527-530
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Potential benefits for patients / the
public Better quality of care Improve health
outcomes Improve consistency of care Inform
patients / public about what health professionals
should be doing Empower public to
make more informed choices Influence public
policy Promote distributive justice
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Potential benefits for healthcare
professionals Better quality of management
decisions Reassure healthcare professionals that
practice / intervention is
appropriate Provide explicit recommendations to
guide care / public health
interventions Reduce outdated, ineffective or
wasteful practice Support quality improvement
initiatives Inform the research agenda by
highlighting gaps in evidence
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Potential benefits for healthcare
systems Improve efficiency Optimise value for
money Demonstrate adherence to guidelines may
improve public image
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What can GUIDELINES offer to improve the
standard of practice?

• Provide clear statements and standards for the
  delivery of care/service locally
• Clarify roles and responsibilities
• Support the implementation of evidence-based
  practice
• Promotes high quality, effective care / service
• Support risk assessment and management
• Provide opportunities for the public to become
  involved in developing services
• Provide a source of information for the CG
  Committee
• Provide audit information
• Promote high quality record keeping

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• How are evidence-based guidelines developed?
• Identifying and refining the subject area of a
  guideline
• Running guideline development groups
• Identifying and assessing the evidence
• Translating evidence into a clinical practice
  guideline
• Reviewing and updating guidelines

Shekelle PG, Woolf SH, Eccles M, Grimshaw J.
Developing guidelines. BMJ 1999 42 67-81
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GUIDELINE DEVELOPMENT PROCESS
Looking at how
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HPS Proposal
GUIDELINE DEVELOPMENT PROCESS
TOPIC SELECTION SCOPE
COMPOSITION OF THE GUIDELINE DEVELOPMENT GROUP
Subject Groups Evidence Editing Review
IDENTIFICATION EVALUATION OF EVIDENCE
FORMATION OF RECOMMENDATIONS GRADING
DEFINE RESOURCE CONSEQUENCES
CONSULTATION PEER REVIEW
EDIT PUBLICATION
FORMULATION OF AUDIT PEER REVIEW
CPD
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Health Protection Network (HPN) Guideline
Development Framework
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2. A systematic approach to produce guidance for
HP in Scotland Development of evidence-based
guidelines

• Developing guidelines de novo
• Guidelines on Management of Legionella outbreaks
  and clusters in the community (
  in collaboration with SIGN )
• Guidelines on Prophylaxis and Management of
  Rabies in Humans
• Adapting existing guidelines
• 2.1. From a validated group of guidelines
• Guidelines on Risk Communication (appraisal
  of 7 guidelines)
• 2.2. Local adaptation of one validated
  guideline
• Guidelines on Tuberculosis (based on the NICE
  guidelines)
• 2.3. Review / revision of existing (older) local
  Scottish Guidance
• Guidance on managing E coli O157

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A guideline which fulfils all the institute's
requirements is like the Holy Grail worth
striving for,

but unattainable by mere
mortals

GENE FEDER,


St
Bartholomew's and the Royal London Medical
College, 1993
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Development of evidence-based guidelines

• A common methodology

• Validated (SIGN 50)

• Topic selection and Scope
• Completion of the GDG
• Identification and evaluation of the evidence
• Appraisal tools (SIGN 50)
• AGREE instrument
• 4. Formulation of recommendations
• 5. Editing, publishing and implementing

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3. Challenges in developing E-B Guidelines for
health protection
. .

Resources Stakeholders capacity in harmony with business continuity Training issues Prioritisation criteria
Quality Assurance Competence in search strategy / appraisal skills Criteria to quality assure our own guidance
Pool of Evidence Intrinsic limitations in the hierarchy of evidence Interpretation of epidemiological evidence Integration of extrapolated and induced evidence
Grading of Recommendations Limitations in adopting conventional grading of recommendations Value of expert opinion shared knowledge from practice
Consultation and Peer Review Access to experts Consultation beyond geographical boundaries Applicability and implementation issues
. .

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• Challenges in grading recommendations
• Intrinsic to the nature of Health Protection (1
  of 2)

Formulating recommendations
RCT
Systematic Reviews
Pool of Evidence Hierarchy of evidence
Grading
Cohort
Case control
Strength of recommendation (1) A high level of
evidence B C D GPP Good Practice Point
Case series
Case Report
E-B Guidelines on Health Protection HPN / HPS
Legislation Codes of Practice
Grey Literature
(1) Grades of Recommendation from SIGN 50. Jan
2008
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• Challenges in grading recommendations
• Intrinsic to the nature of HP (2 of 2)

E-B Guidelines for Health Protection
no no some D GPP
?
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4. Key Considerations

• Good understanding of whats needed to produce
  good quality guidelines
• Provide clear statements and standards for the
  delivery of care/service
• Clarify roles and responsibilities
• Support the implementation of evidence-based
  practice
• Promotes high quality, effective care / service
• Propose a validated method to systematically
  produce guidelines and test it test it test
  it
• acknowledge limitations investment /
  prioritisation
• try resolve the scientific challenges amongst
  the wider community
• A path to solution
• Collaboration (NICE/SIGN RKI/ECDC HPA)

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Thanks
Alex Sánchez-Vivar alex.sanchez-vivar_at_nhs.net
In order to move forward, we need two legs
action and reflection Gaudi
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What are evidence based guidelines?
Mechanisms to improve the quality of health
care and decrease costs and
utilisation Recommendations devised to influence
decisions about health
interventions Tools to outline procedures
which
operate the implementation of evidence-based
practice
Decision tools to close gaps between current and
optimal practice
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Good Practice GUIDELINES Derived from
Institute of Medicine Committee to Advise the
Public Health Service on Clinical Practice
Guidelines. Clinical Practice Guidelines
Directions for a new program. Washington DC
National Academy Press, 1990.
Systematically developed statements to assist
practitioners (and public) to make decisions
about appropriate public health interventions
for specific
circumstances
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