bluuebunny/crossref_metadata_2025 huggingface dataset:
P135 Using Current Practice Information to Identify Areas Of Variation
Authors: Lacey T , Ayiku L , Shaw E , Baillie N
Published: August 2013

Background

Quality standards describe high-priority areas for quality improvement in a defined area.

Objectives

To describe the processes by which areas for quality improvement are identified for quality standards.

Methods

A topic overview, which describes core elements of the standard, such as the population and condition or services to be covered, is published on our website at the beginning of development. We then request written submissions from specialists and registered stakeholders asking them to i identify key areas for quality improvement ii provide examples of published information on current practice (such as, reports of variation in care, evaluations of guidance compliance, or patient experience) to support the identified areas. We also undertake a focused literature search for published current practice information (such as descriptions of practice variation) and identify national audits.

Results

To date, we have undertaken at least 10 such reviews. We will present the types of information we receive, challenges (with a specific focus on quality of information and certainty of decisions made). We will also present how this information was used to identify area for improvement, and whether these decisions were valid.

Discussion

We consider this a novel and practical approach to identifying improvement areas, bringing together views from a diverse audience, supplemented with published information.

Implications for Guideline Developers/Users

Guideline developers could use similar methods to identify areas where evidence based recommendations could be focused, to define and guide best practice.
P143 Projet Jalons: A Provincial Adaptation Of Clinical Practice Guidelines For Depression In Primary Care
Authors: Roberge P , Fournier L , Brouillet H
Published: August 2013

Background

The development of a care protocol for major depression in primary care emerged as an extension of a knowledge application programme developed in Quebec (Canada) to improve care for anxiety and depressive disorders in primary care (2012; JALONS:http://www.qualaxia.org/ms/jalons/). The main goal of the project was to develop or adapt tools to support primary mental health care providers in their clinical practice.

Context

The 2005 reform in Quebec’s mental health services aimed at strengthening primary care services, and included the creation of multidisciplinary community-based primary mental healthcare teams.

Description of Best Practice

We used the ADAPTE method to develop a care protocol for major depression in primary care tailored for the local context, with a consideration of the organisation of health care services in primary care. The work was monitored by an expert committee composed of mental health specialists, general practitioners, health care administrators and decision-makers at regional and provincial levels. The care protocol is based on two clinical practice guidelines: the NICE guideline on the treatment and management of depression in adults (2010) and the CANMAT clinical guidelines for the management of major depressive disorder in adults (2009).

Lessons

We will share the challenges associated with the adaptation of clinical recommendations and organisational strategies to the local context, and the actual implementation of the care protocol in primary care. We will discuss issues dealing with the applicability and successful uptake of recommendations in local contexts (ex.: availability of resources for guideline adaptation, types of professionals involved, barriers).
P146 Adapting and Implementing Guidelines For Chronic Obstructive Pulmonary Disease (COPD)
Authors: Pham C , Koster M
Published: August 2013

Background

Adaptation of high-quality external guidelines can be an efficient and effective means to develop guidance more rapidly, allowing for shifting of resources to knowledge transfer and health system implementation efforts.

Context

To describe successful guideline adaptation and implementation strategies used by a large US health care organisation to improve the quality of care for adults with chronic obstructive pulmonary disease (COPD).

Description of Best Practice

A multidisciplinary guideline team evaluated and adapted a guideline on Chronic Obstructive Pulmonary Disease (COPD) developed by the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society (ACP/ACCP/ATS/ERS). Recommendations were evaluated and modified for implementability based on several dimensions of the GLIA tool. Implementation strategies targeted to physicians included electronic distribution of guidelines, interactive online continuing medical education, and point-of-care encounter support. Implementation efforts targeted to patients included point-of-care education booklets, online resources for COPD self-management, and proactive outreach for spirometry testing. Systems- level interventions included development of patient outreach lists and computerised decision support. Monthly reporting and review on three measures was conducted to monitor performance. Ongoing implementation efforts resulted in increased rates of spirometry testing and management of COPD exacerbations with systemic corticosteroid and bronchodilator medications over a four-year period.

Lessons

Challenges arise when externally developed guidelines lack the specificity necessary for recommendations to be successfully implemented. Systematic evaluation and modification of recommendations is necessary to enhance implementability at the patient, provider and systems levels, as well as to improve performance.
P150 Translating Recommendations Into Clinical Decision Support: Cancerlinq Prototype Experience
Authors: Duffy E , Michel J , Jue J , Erinoff E , Coates V , Mann J , Temin S
Published: August 2013

Background

The Guideline Elements Model (GEM) has been widely used to translate natural language clinical practice guidelines (CPGs) into clinical decision support (CDS) using a highly replicable, guideline-centric approach. A CPG recommendation-to-CDS translation process, which uses GEM-processed content to support an oncology rapid learning system (RLS) prototype, is examined here.

Objectives

To develop rules for a breast cancer-specific CDS prototype using GEM-processed guideline content.

Methods

We created five breast cancer patient scenarios with expert input from oncologists based on nine published CPGs. Using the Yale Center for Medical Informatics-developed GEM Cutter III editor, we parsed the narrative CPG recommendations into an XML-based, machine-readable format. GEM-processed content was then encoded into a Drools business rule management system to develop an integrated platform prototype for rules, workflow, and event processing. We used meta-tags to create value sets for key components of each recommendation by selecting terms from UMLS vocabularies, including SNOMED CT and LOINC.

Results

Forty-five recommendations spanning nine CPGs were processed and converted into Drools rules. We identified 138 decision variables and 91 actions within the selected recommendations. From these, we encoded 148 concepts associated with value set meta-tags and 238 decision rules.

Discussion

The level of difficulty required to encode the recommendations was directly related to the specificity, complexity, and decidability of each recommendation; there was significant variability among the recommendations.

Implications for Guideline Developers/Users

CPG developers may need new processes in order to optimise recommendations for incorporation into CDS systems.
P189 Ischemic Stroke: Through Adapted Clinical Guideline To Local Clinical Protocols
Authors: Morozov A , Stepanenko A , Chagarna N , Shylkina O
Published: August 2013

Background

The health care system of Ukraine required improvement in treatment of stroke patients based on evidence present in GIN.

Objectives

To compare Ukrainian treatment practices with the best strategies for stroke management and to improve quality of health care on the basis of the identified differences.

Methods

Multidisciplinary working group has prepared adapted guidelines “Modern principles of diagnosis and management of patients with acute ischemic stroke and TIA”, “Recommendations for the management of patients with ischemic stroke and TIA”, “Rehabilitation, prevention and management of complications and discharge planning in ischemic stroke” with regard of the evidence-based strategies for stroke treatment. Simultaneously, unified clinical protocols of medical care “Ischemic stroke” and “Systemic thrombolysis for stroke” were developed on the basis of the guidelines and then approved by the Ministry of Health of Ukraine in August 2012.

Results

There were identified differences in the stroke treatment in Ukraine compared to the best practice, which resulted in amendments to the corresponding regulations in health care. In order to integrate these changes into clinical practice local protocols and critical pathways for management of stroke are developing in all healthcare facilities taking into account peculiarities of the region and available resources of the hospitals.

Discussion

Local protocols comprise evidence-based statements which represent the best practice from clinical guidelines from GIN and other databases.

Implications for Guideline Developers/Users

Measures enabling changes in existing medical practice are identified to ensure effective treatment of stroke patients within 4.5 hours after symptoms onset.
P190 Registry Of Medical Technological Documents For Supporting Guidelines Accessibility
Authors: Morozov A , Stepanenko A , Lishchyshyna O , Gorokh Y , Khachaturyan V
Published: August 2013

Background

The Ministry of Health of Ukraine has approved the methodology for development of medical and technological documents on the basis of evidence. The first documents on the basis of evidence were developed by multidisciplinary working groups in recent years. We can witness the process of guidelines adaptation and their implementation into health care practice.

Context

It is necessary to ensure the availability of new documents for doctors, health care providers, and public. Transparency at all stages of medical and technical documents development is also very important.

Description of Best Practice

The website of the registry of medical and technological documents has been created and posted athttp://www.dec.gov.ua/mtd/index.html. The website includes: - Adapted clinical guidelines and unified clinical protocols of medical care developed by multidisciplinary working groups; - Draft documents submitted for public discussion; - Information on clinical topics under consideration; - Methodological materials for developers - members of multidisciplinary working groups; - Links to international sources of evidential information. The development of the content of the website continues.

Lessons for Guideline Developers, Adaptors, Implementers, and/or Users

Creating a specialised website that integrates methodological materials, adapted clinical guidelines, unified clinical protocols, and information about the documents under consideration provides accessibility of documents, convenience for users, and improves confidence of professionals and the public in new documents.
P196 Updating the Evidence For CPGs: The Usefulness Of RSS Feeds
Authors: Etxeandia-Ikobaltzeta I , Ibargoyen-Roteta N , Roteche-del Campo R , Etxeberria-Agirre A , Callén-Blecua M
Published: August 2013

Background

Scientific knowledge is in constant evolution and even if Clinical Practice Guidelines (CPGs) get out of date in five years time, there is a lack of standardised method for an efficient updating process.

Context

A proposal used to update efficiently the bibliographic searches during the development of a CPG on childhood asthma management is described.

Description of Best Practice

Bibliographic searches were performed in Medline, Embase and All EBM databases using Ovid, and in BMJ update database. Search strategies and RSS-feeds were created and saved when possible. E-mail alerts for those searches carried out in databases with no RSS services were also created. All the RSS-feeds were centralised in a Netvibes web portal and organised into tabs (one tab by clinical question). New alerts were revised periodically during the guideline development process and new references incorporated in the guideline when relevant. RSS-feeds could be created for Medline and Embase searches. The centralization of RSS-feeds in a Netvibes portal facilitated the reviewing process of the latest published articles by clinical question. The review of the email-alert services generated for those sources with no RSS services was more time-consuming.

Lessons-for-Guideline-Developers-Adaptors-Implementers-and/or-Users

The management of RSS-feeds is considered as a more effective tool to check and follow all the new references published during the guideline development process, being useful also after the CPG publication. Nevertheless, not all databases allowed the creation of RSS feeds, an issue that should be considered by their managers, and in all cases, the updating process has to be supported by professionals.
P212 Review of Systematic Reviews Related to Clinical Guidelines Implementation
Authors: Geba D , Chan W , Moreno M , Pearson T
Published: August 2013

Background

Clinical guidelines should be implemented using evidence-based implementation strategies. However, guideline development programmes rarely allocate resources to perform evidence-based reviews of implementation strategies required to implement their guidelines. A streamlined approach to obtain such summaries of evidence in preparation for development of cardiovascular risk reduction guidelines sponsored by a national-level organisation was a review of systematic reviews (SRs) of implementation strategies.

Objectives

To explore whether SRs of implementation strategies provide support for the effectiveness of these strategies. Methods Rx for Change database of the Canadian Agency for Drugs and Technologies in Health (CADTH) was selected a priori as data source for this review of systematic reviews. The review was limited to high quality SRs of interventions targeting clinicians.

Results

A total of 12 SRs met study inclusion criteria. These SRs suggest that implementation strategies, such as audit and feedback, academic detailing, and educational meetings, are generally effective in improving providers’ behaviours, with small to moderate effect sizes.

Discussion

This review of SRs provides support for the overall efficacy of guideline implementation strategies, while highlighting the need for further comparative and cost effectiveness research to address gaps in the knowledge identified (e.g., limited information on head-to-head comparisons between strategies, clinical context, and cost of interventions).

Implications for Guideline Developers/Users

Guideline developers should include recommendations for guideline implementation in their future guidelines. Making specific recommendations on choosing one implementation strategy over the others should be avoided until further head-to-head comparisons are available.
P268 What Kind Of Evidence Supported The Clinical Practice Guideline For The Syndromic Management Of Sexually Transmitted Infections And Other Infection Of The Genital Tract 2012
Authors: Gaitan H , Torres M , Rodriguez A
Published: August 2013

Background

In recent years, the GRADE approach has been broadly accepted by many GDG. There is a lack of information about the relationship between the types of evidence with the strength of recommendations using GRADE.

Objective

To present the evidence mapping of the literature used to develop recommendations in the Guideline for Syndromic management of the Genital Tract Infections.

Methods

The evidence of each recommendation was reviewed and was classified according to the type, quality and quantity of evidence and strength of the recommendation. A descriptive analysis was performed as well as a cross-analysis to find out the relationship between the strength of the recommendation and the underlying quality of the evidence.

Results

80 recommendations were identified. Systematic reviews supported the 29.1% of the recommendations, RCT 25.6%, observational studies 5.9%, guidelines 9.3% and expert opinion 30.1%. The quality of the evidence was high (14%), moderate (15%), low (16%) and very low (55%). 63.7% of the recommendations were strong in favour. 14% of the strong recommendations came from high quality evidence and 49% came from very low quality evidence.

Discussion

The evidence shows a similar percentage of systematic reviews, RCT and expert opinion in the guideline. Despite the quality of the evidence, the number of strong recommendations is high due to the other criteria of the GRADE approach.

Implications for Guideline Developers

The GRADE approach allows weighting other factors beyond the quality of the evidence. Research needs to be done on the most important factors in grading the recommendations.
P281 Applying The Re-Aim Framework To Evaluate Dissemination And Implementation Of Clinical Practice Guideline For Sexually Transmitted Infections In Korea
Authors: Jo H , Chang S , Lee Y , Shin E , Oh M , Oh H
Published: August 2013

Background

Clinical practice guideline for Sexually Transmitted Infections were developed in 2011 by The Korean Urological Association supported financially by the Korean government. It is necessary to establish the theory-based strategy to disseminate and implement guideline more effectively.

Objectives

To evaluate dissemination and implementation of clinical practice guideline for Sexually Transmitted Infections in primary health care in Korea.

Methods

The RE-AIM framework in terms of reach, effectiveness, adoption, implementation and maintenance was applied. Structured questionnaire was formulated. Survey was performed by e-mailing to physicians working at primary health care clinics from 1st Nov – 30thNov 2012 and 305 physicians responded.

Results

Of the total respondents, 37.5% answered ‘Reach’- no problem for the accessibility of clinical guidelines, cognitive level, and adoption. For Effectiveness measurement, the use of practice guidelines would help the determination of the direction of treatment and communication with patients (52.2%). For the Adoption-environment to apply clinical practice guidelines, there were no problems (50.6%). For Implementation-the degree of application with Practice Guidelines, 17.8% of respondents frequently used the guidelines and, 91.0% of respondents are willing to use them in the future. For Maintenance, 54.8% of respondents used the clinical practice guidelines for more than 6 months.

Discussion

The reach has been low and even in the respondents with the guideline, the rate of clinical application has been low as well.

Implications for Guideline Developers/Users

RE-AIM framework is a useful tool to evaluate the effect of using guidelines and develop strategies to disseminate them.
064WS How to Use the GRADE ”Evidence-to-Recommendations Framework” to Develop Guideline Recommendations for Therapeutic Interventions
Authors: Schunemann H , Brignardello-Petersen R , Chan W , Alonso-Coello P , Koster M , Robbins C
Published: August 2013

Background

Moving from evidence to recommendations in guideline development requires balancing evidence quality with the benefits and harms of therapeutic interventions, patient preferences, and resource and cost considerations. The GRADE Working Group has developed an approach to integrate these factors into development of clinical practice recommendations that is currently further defined in the DECIDE (Developing and Evaluating Communication Strategies to Support Informed Decisions and Practice Based on Evidence) project.

Objectives/Goal

To train guideline developers and those working with guideline panels to facilitate the decision-making process for development of recommendations for therapeutic interventions using the GRADE “Evidence-to-Recommendations Framework.”

Target Audience

Guideline developers, especially those working with guideline panels to develop recommendations for clinical practice.

Description of the Workshop and of the Methods used to Facilitate Interactions

An overview of the GRADE “Evidence-to-Recommendations Framework” will be followed by facilitated small group work to develop guideline recommendations. Participants will work together in a simulated guideline panel, and be asked to develop guideline recommendations taking into consideration the quality of evidence from a GRADE evidence summary profile, the balance of benefits vs. harms of an intervention, patient preferences and resource implications. Facilitators will guide the small workgroups through the decision-making process using materials from recent examples of guidelines developed using the “Evidence-to-Recommendations Framework.”
P312 A French Project Of Interregional And Shared Guidelines In Supportive Care
Authors: Farsi F , Klein I , Jovenin N , Labrosse H , Brunet M , Block V , Krakowski I
Published: August 2013

Background

In France, access to supportive care is a right for cancer patients It is enshrined in the health regulations (1st and 2nd national cancer plans). But equity in this access is still evolving. In this context a national learned society and the regional oncology networks are desired to support professionals by organising the sharing and exchanges on the decision support tools

Objectives

Gradually enlist all French regional cancer networks and all French experts in selecting the priority thematic, methodological support in the working groups and in objectives of implementation involve the maximum of professionals in the re-reading and validation of shared guidelines

Method

Establishment of a national committee dedicated to supporting methodological and organisational project. - Needs analysis and choice of themes by regional cancer networks - recruitment of experts by both the networks and the learned societies - establishment of inter-disciplinary working group - organisation of a re-reading solicitant learned society and cancer networks - National Day (J2R) with dedicated workshops and plenary sessions to confirm or update the guidelines.

Results and Conclusion

After 4 years, this project with regional networks complete 30 different shared guidelines and the attended by professionals of all the French regions (oncologist; surgeons, supportive care specialists, nurses).
313WS Electronic multilayered guideline format: a novel structure and presentation of trustworthy guidelines at the point of care
Authors: Kristiansen A , Vandvik P , Alonso-Coello P , Rigau D , Brandt L , Guyatt G
Published: August 2013

Background

The DECIDE Project – created by the GRADE Working Group and funded by the European Union – aims at developing and evaluating strategies to improve dissemination and uptake of evidence-based recommendations. Work Package I targets health care professionals and has developed an electronic multilayered guideline format that includes the top layer; consisting of the minimum set of information components deemed necessary for clinicians to act on a recommendation. The first phase of iterative refinements through stakeholder feedback and user testing is completed and we’re now initiating the second phase consisting of surveys and randomised trials of alternative formats.

Objectives

To update participants on the DECIDE project (WP1) and gather feedback on current and alternative guideline formats.

Target Group

Guideline developers.

Description

The workshop will open with an introduction to the background and progress of the DECIDE project/WP1. Participants will be given a clinical scenario together with relevant examples of guidelines after which they’re asked to provide anonymous information on attitudes and perceptions of trustworthy guidelines, the use of GRADE and current presentation formats. Following this they’ll be given a systematic review on the same subject and asked to write a draft recommendation in the top layer format using a prototype online authoring tool tailored for the format. Participants will at the end of the session be asked to provide feedback on the novel format, specifically on relevance, comprehension, likability and feasibility of production. Feedback is collected using a multiple-choice survey with clickers in addition to a final discussion
P340 Sources Of Information For Development Of Clinical Practice Guidelines In Japan
Authors: Hatakeyama Y , Okumura A , Takahashi N , Yoshida M , Kojimahara N , Kiyohara K , Sato Y , Htun N , Group MINDS , Yamaguchi N
Published: August 2013

Background

A Systematic search for literature is the basis of systematic review for development of trustworthy clinical practice guidelines (CPGs). Recently, standard method of literature search has been established. However, it is not clear what sources of information are used for development of CPGs in Japan.

Objectives

The aim is to clarify what sources of information are used for development of CPGs in Japan.

Methods

We reviewed Japanese CPGs that have been selected by MINDS (Medical Information Network Distribution Service) through process of screening and evaluation in 2011-2013, and abstracted description about sources of information used in these CPGs in February 2012.

Results

A total of 88 Japanese CPGs selected by MINDS in 2011-2013. 65 (73.9%) CPGs used Medline, 29 (33.0%) used Cochrane database of systematic reviews, and 51 (58.0%) used Ichushi. Related CPGs was used in 30 (34.1%) CPGs. Hand search was used in 56 (63.6%) CPGs. There was no clear description of source of information in 18 (20.5%) CPGs.

Discussion

Medline was used in most CPGs, and Cochrane database of systematic reviews was used in a relatively small number of CPGs. Ichushi, which is a database of domestic medical literature information in Japan, was used in about a half of Japanese CPGs.

Implications for Guideline Developers/Users

It is necessary for further study to clarify what sources of information should be used for development of trustworthy CPGs.
P352 Game-It (Games For Improving Treatment-Recommendations)
Authors: Brandt L , McCallum S , Kristiansen A , Agoritsas T , Akl E , Vandvik P , Montori V
Published: August 2013

Background

Traditionally patients are not involved in the development of clinical guidelines, and most current panels include only clinical and methodological experts. We therefore know little about what patients (or healthy lay people) would have recommended if they were provided with the same evidence as experts.

Objectives

Develop a prototype ‘Recommendation-making game’ which can be used for: (1) Exploring patients and lay people’s reasoning when facing the same evidence as an expert guideline panel; (2) assess whether they give similar value to the outcomes or burdens if the decision of making a recommendation for a patient group was up to them; (3) determine whether their recommendation concur with what they would have decided for themselves.

Methods

We used game technology to make a generic prototype of an online “Recommendation-making game”, based on structured guidelines published in the MAGIC (Making Grade the Irresistible Choice) application. This approach will enable us to automatically make online surveys out of any guideline/recommendation in the system. In making it into a game we believe people would want to participate, and we can potentially harvest information from a large group of people. The game can also be used in small focus groups for qualitative data collection.

Results

We will display the prototype at the conference.

Discussion

Does clinical experts reasoning effects that of patient representatives in a guideline panel?

Implications for Guideline Developers/Users

GAME-IT explores a new way of harvesting information from patients (or healthy lay people) regarding treatment recommendations.
001 DECIDE: User Involvement in Guideline Development
Authors: Callaghan M , Harbour R
Published: August 2013

The European Union funded project, DECIDE aims to improve the dissemination of evidence based recommendations by building on the work of GRADE. Work Package 3 aims to identify approaches to effective dissemination and use of research evidence by the general public, in order to improve shared healthcare decision making and person-centred care. This part of the study explores public understanding of clinical guidelines and preferences over future presentation. Focus groups were carried out, to discuss specific guidelines (depression, diabetes, flu vaccination and cervical cancer), and with professionals working in science communication and young people. Questions were informed by a systematic literature review. Data were analysed using the Framework method. Those with experience of a specific illness were better informed and more likely to have actively sought out information than those targeted for screening. Themes emerged including: participants not understanding the concept of ‘strong’ and ‘weak’ evidence; participants feeling information should be presented more clearly with emphasis on self-management and side effects; concern expressed that treatment decisions were based on cost rather than evidence; and participants wanted more general information on the condition. Aspects of the content and presentation of guidelines are not relevant or understood by the public. Several different versions of these guidelines have been created based on these results and user testing is ongoing. Current clinical guidelines will need to be adapted substantially before they are appropriate for the public, and the public should be involved in guideline development on an ongoing basis.
012 Development of an Analytic Framework for Making Evidence-Based Coverage Policy Decisions
Authors: King V , Vandegriff S , Little A , Coffman D , Livingston C , Shaffer W , Gingerich J
Published: August 2013

Background

Comprehensive health reform legislation in 2009 directed a US state to develop processes by which evidence can be translated into coverage guidance, and be applied rapidly and uniformly across public and private settings.

Context

Topics for development of coverage guidance were chosen if they represented a significant burden of disease, had important uncertainty with regard to efficacy or harms, had important variation or controversy in clinical care, significant economic impact and/or were of high public interest.

Description of Best Practice

A list of evidence sources was developed and vetted through the Governor-appointed committee that manages the state Medicaid benefit package. An analytic framework algorithm was developed to guide coverage decisions that consider six stepwise decision points: sufficiency of evidence; effectiveness of the treatment and availability of alternatives; treatment risk; cost; prevalence of treatment and feasibility of clinical research studies. The GRADE process was also used to specify the addition of patient values and preferences as a factor. The algorithm allows the committee to determine whether a service is recommended or not, with two levels of strength of recommendation (strong and weak). Using a public process, the committee has reviewed the evidence and has made coverage policy recommendations for 15 topics, to date. Decisions have been applied to Medicaid, and are also made available to other public and private payers.

Lessons for Guideline Developers, Adaptors, Implementers, and/or Users

Use of a discreet analytic framework can aid in the development of coverage decisions, and may accelerate the dissemination of research evidence into clinical practice.
017 Guideline Based Performance Measures: towards G-I-N Standards
Authors: Nothacker M , Shaw T B , Stokes T
Published: August 2013

Background

Quality improvement in health care requires the development and use of performance measures (PMs) that address health care processes, outcomes and patient perspectives. PMs are increasingly being developed explicitly from clinical guideline (CG) recommendations. There are no agreed international standards for the development of guidelines based PM. The development of such standards has been agreed by the G-I-N-PM Working Group (PMWG).

Objectives

To develop a core set of standards for guidelines based PMs.

Methods

• Systematic literature review of PM development methods • Identification of core components of guidelines based PM development • Development of draft standards for each core component • DELPHI process (at least 2 rounds) within the PMWG group to develop final set of standards

Results

Essential components identified are: CG selection, extraction of CG recommendations, development of PMs from CG recommendations, assessment of potential PMs, intended use of PMs, piloting and review of PMs. The final agreed standards will be presented.

Discussion

These guideline based PM standards will be refined and validated in future G-I-N PMWG projects.

Implications for Guideline Developers/Users

This set of core standards for guideline based PM development offers guidance for PM developers on consensus based good practice. The resulting PM development process may also guide guideline developers to formulate more specific and measurable CG recommendations.
P005 Do guidelines guide the clinical practice?
Authors: Sang il Lee
Published: August 2013

Clinical practice guidelines and performance measures can be used to improve quality of health care. Medical review criteria and performance measures are used to determine the extent to which care has followed specified processes and whether the expected outcomes have been achieved. Recently there are increasing tendencies to release the healthcare organisations’ performance to the public and to introduce pay-for-performance in many countries.

In countries where development, dissemination, and implementation of clinical practice guidelines are relatively slow, other interventions such as claims review activities, report cards, and pay-for-performance may have stronger influence on clinical practice in the real world than guidelines. In this presentation issues around the relationship among clinical practice guidelines, performance measures, claims review criteria, and clinical practice in the settings where guideline activities are not so active will be discussed
019 Successful Implementation of Cardiovascular Prevention and Treatment Guidelines in an Integrated Health Care System: Structure, Process and Outcomes
Authors: Harris J , Jaffe M
Published: August 2013

Background

Evidence based guideline recommendations can support effective prevention and treatment of cardiovascular disorders, leading causes of morbidity and mortality in our population. Improvements result if recommendations are implemented in a uniform and effective manner.

Objectives

To describe the process, structure and results of efforts to better manage cardiovascular risks and events in an integrated health system using organisational best practices; To present results of risk reduction, disease management and acute care programmes.

Methods

Database analyses revealed opportunities for improvement. Pilot projects were conducted, followed by training about successful processes and practices, supported by organisational leaders. Ongoing comparative feedback supports improvements. Suggested order sets are incorporated in the EMR. Financial incentives for meeting targets accrue to medical centres.

Results

The incidence of acute myocardial infarctions dropped significantly in the last 5 years, as did the mortality rate. Stroke mortality dropped significantly as well. The population levels of lipids, blood sugar, blood pressure and CHF control continue to improve.

Discussion

Guideline recommendations were adopted across our delivery system when supported by top leadership, testing, training, specific care processes, EMR prompts for tests and treatments, regularly reviewed process metrics and group financial incentives. Practice variance was reduced and outcomes markedly improved.

Implications for Guideline Developers

Guideline recommendations are more likely to be adopted in a uniform manner if they include specific recommendation, suggestions for implementation use in organised settings, and process and outcome metrics to track improvements.
020 Best Practices and Performance Measures for Systemic Treatment Perscriber Order Entry Systems (STCPOE) in Chemotherapy Delivery
Authors: Kukreti V , Cheung A , Hertz S , Kaizer L , Lankshear S
Published: August 2013

Background

While information technology (IT) has the potential to improve the quality and safety of patient care, solutions such as computerised physician order entry (CPOE) are often designed and executed without end-user involvement and lack performance measures for monitoring quality and impact. To address this gap, an evidence based guideline for systemic treatment (ST) CPOE was developed incorporating both clinical and technological best practices. Performance measures for monitoring clinical impacts and system functionality were also developed.

Context

The ST CPOE guideline was developed by a panel of physicians, nurses, pharmacists, IT specialists and human factors experts. Two Expert Panels (i.e. Clinical and Technology) were convened, to review and provide feedback on guideline content.

Description of Best Practice

The guideline contains two distinct yet interconnected parts: clinical practice (e.g. error prevention, utilisation, clinical decision support), and technology requirements (e.g. usability, system integration, effective alerts). Also included are evidence based indicators to support the evaluation of ST CPOE systems and indicators reflecting clinician practice and patient outcomes. Quality monitoring of ST CPOE utilisation reveal that 75.5% of all chemotherapy visits are being supported by an ST CPOE system. A provincial evaluation of existing ST CPOE systems against the technology best practices is currently underway.

Lessons for Guideline Developers, Adaptors, Implementers, and/or Users

This innovative guideline focuses on clinical practice driving IT solutions, not the other way around. A priori commitment to indicator development allowed for expanding beyond describing best practices to including indicators for monitoring progress toward achieving best practice, thus increasing relevance and uptake by end users.
030 Primary Care Physicians’ Views On Relevance Of Clinical Guideline Recommendations: Delphi Panel
Authors: Steel N , Abdelhamid A , Stokes T , Fleetcroft R , Qureshi N , Howe A
Published: August 2013

Background

National clinical guideline developers, such as the UK’s National Institute for Health and Clinical Excellence (NICE), produce high quality guidelines, yet primary care practitioners (PCPs) may question the relevance of the evidence and recommendations to a primary care (PC) population.

Objectives

To evaluate PCPs’ views about the relevance of NICE clinical guidelines to PC.

Methods

An online Delphi panel of 28 PCPs, recruited regionally and nationally, reviewed 14 guideline recommendations: 8 supported by PC relevant evidence and 6 by evidence from elsewhere. Panellists scored recommendations twice, on a scale of 1–9 (9 = highly relevant for PC), before and then again after reading a summary of the evidence, including study setting and population. They also commented on factors influencing guideline validity and PC implementability.

Results

25 PCPs (89%) completed the Delphi. Overall mean scores were 7.4 (range 6.2–8.2) before reading the evidence summary, and 6.6 (4.6–8.3) after. Mean scores for the 8 recommendations supported by PC evidence were 7.4 before and 7.2 after (change -0.2). Mean scores for the 6 with evidence from elsewhere were 7.4 before and 5.8 after (change -1.6). Factors perceived to influence implementation included clarity, brevity, and relevance to PC.

Discussion

PCPs’ ratings of PC guideline validity dropped when they became aware that substantial supporting evidence for the guidelines had come from non PC settings. The relevance of the evidence to PC patients was important.

Implications for Guideline Developers/Users

Developers should explicitly describe the relevance of available evidence for PCPs and their patients.
041 Making Recommendations About Diagnostic Tests And Strategies: What Do Experts Say?
Authors: Mustafa R , Brozek J , Wiercioch W , Ventresca M , Lloyd N , Schünemann H
Published: August 2013

Background

Current practices in developing guidelines about the use of diagnostic tests and strategies (DTS) are out of step with the conceptual discussion among experts.

Objectives

Identify the essential factors to consider when making recommendations about DTS.

Methods

We conducted semi-structured in-depth interviews with experts in assessing evidence and producing guidelines about DTS.

Results

We interviewed 23 international experts. Although diagnostic test accuracy (DTA) was the factor most commonly considered by organisations when developing recommendations, experts agreed that DTA is never sufficient and may be misleading. Experts identified the following additional essential factors in making decisions about DTS: resource implications, complications, inconclusive results, additional benefits of the test, diagnostic/therapeutic impact, safety, feasibility, ethical, legal, and organisational considerations, patients’ and societies’ values and preferences and the link between the test results and patient important outcomes. Because direct evidence on DTS’s effects on patient outcomes and resource implications is frequently unavailable, most experts agreed that decision analysis and mathematical modelling will be useful, but their opinion varied about the extent of details needed.

Discussion

Formal decision modelling can be a useful framework for organising the clinical, cost, and preference data relevant to the use of diagnostic tests. Although it requires resources, it is useful for integrating these factors into decision making, identifying evidence gaps, and high priority research areas.

Implications

Developing guidelines about the use of DTS requires considering factors beyond solely DTA but implementing this demand is challenging. Further development and testing of a framework that can guide this process is needed.
044 Collegial Collaboration Managing Joint Projects Across Societies
Authors: Fatheree L , Wick M , Larsen S , Olsen J
Published: August 2013

Background

Pooling resources for the development and dissemination of guidelines receives important consideration due to the extensive amount of expertise, money and staff time needed within an organisation. Partnered guidelines may increase the administrative cost and timeline of development, but is positively offset in the value partnering brings in the ultimate success and implementation.

Context

Over the last three years we formally partnered with other professional medical societies in over 70% of our guidelines, learning many core and nuanced components of a successful jointly-developed guideline. We share those lessons learned with GIN members.

Description of Best Practice

We tackle critically important aspects of joint collaborations, beginning with the determination of appropriate partners. We explore the creation of a solid memorandum of understanding (MOU), addressing questions like: How will we select panel membership and manage their conflicts of interest? What grading system will we utilise with an evidence-based guideline or consensus conference? How will we approach our respective organisation’s approval process? What is needed to produce a simultaneous joint publication between journals? How will we disseminate effectively to our target audiences? What is our future plan for a revision? And the ultimate questions - How do we cost share and work share in the development equally?

Lessons for Guideline Developers, Adaptors, Implementers, and/or Users

These experiences will help guideline developers create a framework for partnered collaborations, balancing value gained in partnership versus challenges realised in completion and resourcing.
045 Strategies for Clinical Expert and Stakeholder Involvement in Updating and Implementing Clinical Guidance for New and Emerging Medical Interventions
Authors: Loughren E
Published: August 2013

Background

Lack of sufficient clinical expert and stakeholder involvement in the routine updating of guidance on new and emerging medical interventions can lead to inefficient use of resources and inadvertently create unnecessary barriers to implementation.

Context

An evidence services unit within a large health care organisation developed a stakeholder-centred process for rapid updating and implementation of guidance related to the use of breast magnetic resonance imaging (MRI).

Description of Best Practice

The process focused on the following: 1) asking clinical stakeholders to identify the indications for which use of breast MRI remained unresolved or controversial; 2) conducting a search for high-quality systematic reviews and clinical trials for the specific indications, and contacting well-known external content experts to identify unpublished evidence; 3) obtaining data on the organisation’s current breast MRI utilisation and practice variation; 4) engaging experts/stakeholders in guidance development and revision based on current utilisation/practice variation compared to findings from the evidence review; 5) obtaining endorsement of guidance and commitment to implementation efforts from clinical opinion leaders and other stakeholders; and 6) initiating routine monitoring and feedback on breast MRI use.

Lessons for Guideline Developers, Adaptors, Implementers, and/or Users

Limiting evidence updates to controversial or unresolved areas of clinical practice, engaging stakeholders in guidance development based on a review of current utilisation data and scientific evidence, and engaging key opinion leaders and stakeholders in implementation and performance monitoring leads to more efficient use of resources, stronger implementation and improved performance.