development and implementation of clinical practice guidelines by prof. dr. h. reinauer
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Development and Implementation of Clinical Practice Guidelines by Prof. Dr. H. Reinauer. Association of the Scientific Medical Societies of Germany (AWMF). New Structure of the Guidelines of the Medical Association on Quality Assurance in Medical Laboratories. - PowerPoint PPT PresentationTRANSCRIPT
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Development and Implementation of Clinical
Practice Guidelinesby
Prof. Dr. H. Reinauer
Association of the Scientific Medical Societies of Germany (AWMF)
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New Structure of the Guidelines of the Medical Association on Quality Assurance in
Medical LaboratoriesPart A: General Requirements
Basic Requirements on the Quality Assurance in Medical Laboratories
Part B: Special Fields:
B1 Quantitative Analyses in Medical Laboratories
B2 Qualitative Analyses in Medical Laboratories
B3 Analyses of infections agents (bacteria, viruses)
B4 Analyses of ejaculate
B5 Analyses in the human genetics
NEW
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Clinical Practice Guidelines: Definitions
Systematically developed statements
to assist physicians and, if necessary, other healthcare professionals and patients
with decisions about appropriate health care in specific clinical circumstances
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.
Institute of Medicine 1990, 2011: http://www.iom.edu
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Basic statement on clinical practice guidelines (CPGs)
CPGs are recommendations
in patient care. They do not
replace the knowledge and
experience of the single
medical doctor.
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• concern about variation, quality, efficiency,and evidence for effectiveness of interventions in health care
• professional interest to define current optimal practice in an era of cost containment
• interest of purchasers (governments, insurers) and patients
• rapid expansion of medical knowledge(more than 1 Million new entries in Medline/PubMed per year)
• understanding of a need for decision aids (not standards)for health care professionals and patients in the individual encounter
Background to Guideline Development
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• ownership and responsibility lie with the profession: guidelines are developed by scientific medical societies
• support, coordination and quality assurance are provided by a national umbrella organisation, AWMF(Association of the Scientific Medical Societies in Germany
– currently representing 168 member societies)
• AWMF strives for networking with national quality initiatives to promote implementation and evaluation of guidelines
• AWMF is the primary contact to the Guidelines International Network (G-I-N)
Background to Guideline Development in the German Health Care System
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Clinical need
Expert group
Draft version Reviewing
Final version Financial limits?
Consens process
Implementation Publication
Reviewing
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Guideline Development:International Consensus
on Methodological Principles
agreetrust.org
iom.edu/Reports/2011
http://www.g-i-n.net
The process by which a clinical practice guideline (CPG) is developed and funded should be detailed explicitly and publicly accessible.
http://www.awmf.org
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Who should
develop and
monitor the
clinical practice
guidelines ?
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Interested organisations
• Federal Medical Association (Bundesärztekammer)
• Association of the Health Insurance Companies
• Scientific-medical societies
• Patient organisations
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http://cebgrade.mcmaster.ca/guidecheck.html
Open access to methodological support:The Guideline Development Checklist
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Stakeholder Involvement:Composition of the Guideline Development Group
The GDG should be multidisciplinary and balanced including representatives of
Professional groups
- medical speciality societies
- professional associations
- methodological experts
Target population and patients
those, who are adressed/affected
by the recommedations
Example:. www.awmf.org
German National Disease Management GuidelineUnipolar Depression: n= 31
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• Document strategy used to search and select evidence in a way it can be reproduced by others
• Identify risks of bias- critically appraise evidence
• Document results: evidence tables / profiles
Rigor of Development:Systematic Review of the Evidence
http://www.g-i-n.net - GIN Evidence Tables Working Group:Template for summarising studiesaddressing Intervention questions
NICE Clinical Guideline 118, March 2011: Evidence profileColonoscopic surveillance for prevention of CRC inpatients with ulcerative colitis, Crohn's disease or adenomas
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• Source(s) of funding- declare sources of funding- make sure funders have no role in CPG development and can not influence the content of the guideline
• Competing interests of guideline development group - declare all interests and activities potentially resulting in COI (commercial, academical and institutional)
- document measures taken to minimize the influence of competing interests on guideline development or formulation of the
recommendations
Editorial IndependenceManangement of Conflicts of Interest
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Knowledge transfer to target group improves motivation
Information is not evidence-based, not communicating absolute numbers (NNT, NNH), not useful in the individual encounter
Driving Forces Restraining Forces (Barriers)
Force Field Analysis
1. Learning Theory
3. Social Theory
2. Behavioral TheoryExternal audit / objective review based on performance measures
Incentives
Benefit for individual professionals unclear, no reimbursement for documentation of performance measures
Communication, Quality Circles
Opinion Leaders
Lack of communication between professionals – especially transsectoral (primary/specialised care; ambulatory/in-hospital care)
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Implementation: evidence-based strategies(e.g. audit and feedback, professional peer review)
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Clinical Practice Guidelines at the Core of the PDCA Cycle
Do
Check
Act Plan
Act
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Criteria for the extraction of guideline recommendations
• impact on patient outcome
• level of evidence, grade of recommendation
• potential for improvement
• measurability
• relevance
• ….
18
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Rigor of Development:from Evidence to Recommendations
Strength of recommendation
do / don´t do„we recommend“
probably do/don´t do„we suggest“
Quality of evidence
2 - moderate
3 - low4 - very low
1 – high
considered judgment a criteria-guided group decision using formal
consensus methods (e.g. Nominal Group Technique)
DM-CPG programme – method report (www.versorgungsleitlinien.de/english/methods)European Council, Recommendation (2001) 13
GRADE 2004 (www.gradeworkinggroup.org)
uncertain„can be considered“
„we do not know“
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Classification of the practice guidelines
S 1: Recommendation of an expert group
S 2: Result of a consensus processS 2k: Formal consensus process
S 2e: Evidence based harmonization
S 3:
Final consensus based on evaluation of the procedure, the clinical use, and the outcome. Final implemented recommendation
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Actual list of the published clinical practice guidelines
class number
S 1 434
S 2 41
S 2e 17
S 2k 124
S 3 130
746
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Number of guidelines in different classes
S 1 S 2 S 2e S 2k S 3Diabetes society 1 5Gynecology 19 2 1 4 2Dermatology 24 2 1 4 2HNO/General medicine
16 2 10
Radiology 30 Neurology 77 5 8
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Frequency of reviewing the CPGs in Germany
Hypertension 15.000/6 months
Diabetes therapy 2.800/6 months
Coronary heart disease 2.500/6
months
Infectious of urinary tract 15.000/6
months
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Clinical Practice Guidelines at the Core of the PDCA Cycle
Do
Check
Act Plan
Act
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Become a G-I-N member
The Guidelines International Network is the
leading organisation that enables organisations
And individuals to work together on issues and
projects related to guideline development,
implementation and research.
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G-I-N aims to
Provide easy access to resources for
organisations and individuals across the
world
Facilitate and foster collaborating within the
network
Provide a platform for members to share
their expertise and information on their
activities and projects
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Main Critics
1) The full versions of the Guidelines are too long to be red and followed immediately. Short versions are rare.
2) To follow the original version in diagnosis and therapy may be too expensive and the costs are not covered by the health insurance companies.
3) The CPGs do not regard the different health care systems (climate, culture, professions, age and gender of the patients).
4) The patients may have different interacting diseases. This is not considered in the guidelines.
5) Judgement of Court of justice on malpractice of medical doctors are primarily oriented by CPGs.
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Conclusions:
„For the future, systematic clinical practice guidelines of the highest quality are on the way , to assure implementation of the best research results in clinical practice – so that EbM is used in each and every patient treatment, everywhere“
(Implementation of Medical Research in Clinical Practice www.esf.org)
concept: national guidelines / evidence profiles as
basis for european consensus on best diagnostic and therapeutic procedures
outlook: networking to avoid duplication of efforts!
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Thank you for your attention !
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Clinical Practice Guidelines at the Core of the PDCA Cycle
Do
Check
Act Plan
Act
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Clinical Practice Guidelines at the Core of the PDCA Cycle
Do
Check
Act Plan
Act
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Clinical Practice Guidelines at the Core of the PDCA Cycle
Do
Check
Act Plan
Act
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Implementation and Monitoring / Evaluation:Networking with existing quality initiatives
OECD Health Indicator Project
• National Network of Certified Centers /Reference Centerssupport implementation, transfer of guidelines into practice
• National Network of Registers assess and report processes and outcomes, provide feedback
• External quality assurance (Germany: implemented in the Social Code book, carried out by a central institution)
assess and report processes and provide feedback
• Outlook: Networking with international initiatives?
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OECD Indicator:OECD Indicator:Antidepressants Antidepressants Consumption Consumption
OECD (2013), Health at a Glance 2013:
OECD Indicators, OECD Publishing.
http://dx.doi.org/10.1787/health_glance-2013-en
Quality Assessment: Mental Health Care Example
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Is this indicator useful?Is this indicator useful?::remaining questionsremaining questions......- overdiagnosis?- overdiagnosis?- lack of specification of- lack of specification of patient target group patient target group (denominator) ? (denominator) ?- underuse of non- underuse of non pharmacological pharmacological interventions? interventions?
Quality Assessment: Mental Health Care Example
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Enhancing Quality:Colorectal Cancer Example
Patients receiving TME Documentation according to Mercury (n= 173)
Performance Measure: Total Mesorectal Excision in Patients with Rectal Cancer (LoE 2a)Source: M. F. Hofstädter, M. Klinkhammer-Schalke 2008
Data base: German Cancer Registries
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Enhancing Medical Professionalism and Interdisciplinarity:is the German bottom-up approach successful?
Enhancing professionalism- improvement in systematic development:Quality Improvement of Guidelines in the AWMF-Register over time
S1 - expert recommendationsS2 - guidelines based on a
systematicreview of the evidence or
onstructured consensus of amultidisciplinary group
S3 – evidence and consenus
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EuropeanGuideline
• national development of evidence profiles and guidelines
• european guidelines: distillation of key recommendations
• networking:umbrella organisations like AWMF, G-I-NEU-Network of Reference Centers and Registries?
Moving forward towards networkingwith guidelines: conceptual suggestion
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Clinical Practice Guidelines
and Quality Management
Association of the Scientific Medical Societies in GermanyInstitute for Medical Knowledge Managegement
Philipps-University Marburg