TEACH LEVEL II: CLINICAL POLICIES AND GUIDELINES STREAM

Craig A Umscheid, MD, MSCE, FACP

Assistant Professor of Medicine and Epidemiology

Director, Center for Evidence-based Practice

Medical Director, Clinical Decision Support

Senior Associate Director, ECRI-Penn AHRQ EPC

TEACH Plenary

August 8th, 2013

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Goal

To gain knowledge, attitudes and skills required to develop and adapt clinical policies and guidelines for implementation in health care.

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Faculty

Karen Schoelles, MD, MS• Director, ECRI-Penn AHRQ EPC

Louise Falzon, MS• Research Librarian, Columbia University, and BCBS AHRQ EPC

Ian Graham, PhD• Vice-President, Knowledge Translation, Canadian Institutes of Health

Research; and Associate Professor, University of Ottawa

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Daily Schedule

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An Illustrative Case: Surgical Site Infections

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Defining the problem and building a team

Building a team to define and address the problem• Multidisciplinary• Executive sponsorship• Consumers• COI

Using evidence as part of the process• Local• Published

Frame or “fit” problem within priorities of leadership to motivate support and solutions

Mitchell MD, et al. Int J Technol Assess Health Care. 2010;26(3):294-300.

Harris C, Turner T and Wilkinson F. Guideline Development Toolkit. 2008.

Lavis JN, et al. Health Research Policy and Systems. 2009, 7(Suppl 1):S4 doi:10.1186/1478-4505-7-S1-S4.

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PICO and Analytic Frameworks

Samson D, Schoelles KM. J Gen Intern Med . 2012; 27(Suppl 1):S11–19.

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Daily Schedule

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Pyramid: 3 dimensional “3-S” model linking study designs to electronic resources

Silva SA, Wyer PC. The Roadmap: a blueprint for evidence literacy within a Scientifically Informed Medical Practice and Learning (SIMPLE) model. The International Journal of Person Centered Medicine. 2012. (In press)

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National Guideline Clearinghouse

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PubMed: Guidelines and Reviews

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Cochrane Library: Reviews and HTAD

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Daily Schedule

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Trustworthy Guidelines

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IOM

IOM domains

1. Establishing transparency

2. Management of conflict of interest

3. Guideline development group composition

4. Clinical practice guideline - systematic review intersection

5. Establishing evidence foundations for and rating strength of recommendations

6. Articulation of recommendations

7. External review

8. Updating

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AGREE II Instrument

Tool to assess the quality of clinical practice guidelines.

Composed of 23 items in 6 domains:• Scope and purpose (3 items)• Stakeholder involvement (3 items)• Rigor of development (8 items)• Clarity of presentation (3 items)• Applicability (4 items)• Editorial independence (2 items)

Two Overall Assessments:• Rating of the overall quality of the guideline• Whether the user recommends the guideline for use in practice

AGREE II: Advancing guideline development, reporting and evaluation in health care. Brouwers et al., Journal of Clinical Epidemiology 63 (2010) 1308e1311

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Daily Schedule

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Hospital-based Health Tech Assessment

J Gen Intern Med. 2010; 25(12):1352–5

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Daily Schedule

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Seven Key Steps for Systematic Reviews

1. Define the question2. Establish eligibility criteria3. Search literature4. Extract data5. Evaluate individual study quality6. Synthesize data qualitatively and/or

quantitatively (MA)7. Explore heterogeneity

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Daily Schedule

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Daily Schedule

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CAN-IMPLEMENT©: a six step model

Tool 4.1o Recommendations Matrix (template)

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Stream Objectives

By the end of this workshop, participants in this stream will be able to:

Knowledge

1.Describe how to define a health care problem and identify questions requiring guideline recommendations2.Describe how to find, appraise, and adapt guidelines and systematic reviews for local use3.Describe the principles involved in doing original systematic reviews of the evidence4.Describe how to formulate actionable recommendations

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Stream Objectives (continued)

Attitudes

1.Recognize the importance of carefully defining questions prior to searching for answers2.Recognize the importance of the contribution of multidisciplinary teams to getting the questions right3.Recognize the importance of appraising the quality of guidelines when selecting a guideline to adapt4.Recognize the importance of adapting guidelines to local context

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Stream Objectives (continued)

Skills

1.Frame questions using an analytic frameworks such as the PICO format2.Develop efficient search strategies corresponding to the analytic framework3.Use tools such as AGREE II to appraise guideline quality4.Use tools such as AMSTAR to appraise the quality of systematic reviews5.Use GRADE or similar principles to synthesize an evidence base and develop actionable recommendations6.Use ADAPTE and Can Implement to adapt national guidelines for local use

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Questions?