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Development of Clinical Practice Development of Clinical Practice Guidelines for the NHSGuidelines for the NHS
Dr Jacqueline Dutchak, DirectorDr Jacqueline Dutchak, Director
National Collaborating Centre for National Collaborating Centre for Acute CareAcute Care
16 January 200416 January 2004
NCC-ACNCC-AC
One of seven Centres set up by NICE in One of seven Centres set up by NICE in April 2001April 2001
Based at the Royal College of Surgeons of Based at the Royal College of Surgeons of EnglandEngland
Staff team comprises systematic reviewers, Staff team comprises systematic reviewers, health economists, statisticians and health economists, statisticians and information scientistsinformation scientists
Commissioned by NICE to produce clinical Commissioned by NICE to produce clinical guidelines for the NHSguidelines for the NHS
Clinical guidelines are...Clinical guidelines are...
recommendations for the care of recommendations for the care of individuals by healthcare professionalsindividuals by healthcare professionals
based on the best available evidencebased on the best available evidence
advisory – they assist the practice of advisory – they assist the practice of healthcare professionals, but do not healthcare professionals, but do not replace their knowledge and skillsreplace their knowledge and skills
Clinical guidelines cover...Clinical guidelines cover...
management of diseases/conditionsmanagement of diseases/conditions
any aspect of management from any aspect of management from prevention & self-care through primary prevention & self-care through primary and secondary care to more specialised and secondary care to more specialised servicesservices
Guidelines should be:Guidelines should be:
ValidValid
ReproducibleReproducible
Cost-effectiveCost-effective
Representative/multidisciplinaryRepresentative/multidisciplinary
Clinically applicableClinically applicable
FlexibleFlexible
ClearClear
ReviewableReviewable
Amenable to clinical auditAmenable to clinical audit
Development ProcessDevelopment Process
1.1. Topic SelectionTopic Selection
2.2. ScopeScope
3.3. WorkplanWorkplan
4.4. Development of the guideline (GDG)Development of the guideline (GDG)
5.5. ValidationValidation
6.6. DisseminationDissemination
7.7. UpdateUpdate
1. Topic selection1. Topic selection
Topics selected by the Dept of Health and Topics selected by the Dept of Health and National Assembly for WalesNational Assembly for Wales
Criteria:Criteria:
– Potential to improve healthPotential to improve health
– Need to reduce variations in clinical Need to reduce variations in clinical practicepractice
– Link with Government priorities.Link with Government priorities.
Topics allocated to NCCs...Topics allocated to NCCs...
Seven National Collaborating CentresSeven National Collaborating Centres– NCC Acute CareNCC Acute Care
– NCC CancerNCC Cancer
– NCC Chronic CareNCC Chronic Care
– NCC Mental HealthNCC Mental Health
– NCC Nursing and Supportive CareNCC Nursing and Supportive Care
– NCC Primary CareNCC Primary Care
– NCC Women and Children’s HealthNCC Women and Children’s Health
Patient Involvement UnitPatient Involvement Unit
NICE delivers remit to the NICE delivers remit to the NCC…NCC…
"To prepare clinical guidelines for "To prepare clinical guidelines for the NHS in England and Wales for the NHS in England and Wales for the diagnosis and treatment of the diagnosis and treatment of lung cancer. This is to supplement lung cancer. This is to supplement the existing service guidance the existing service guidance published by DH in 1998 and this published by DH in 1998 and this commission replaces the earlier commission replaces the earlier commission to update that commission to update that guidance". guidance".
Another remit….Another remit….
““To prepare guidance for the NHS To prepare guidance for the NHS in England and Wales, on the in England and Wales, on the clinical and cost effectiveness of a clinical and cost effectiveness of a dental recall examination for all dental recall examination for all patients at an interval based on patients at an interval based on the risk from oral disease.” the risk from oral disease.”
2. Scope2. Scope
Prepared by the NCC and it outlines ...Prepared by the NCC and it outlines ...– Aspects of care to be coveredAspects of care to be covered
– Background epidemiologyBackground epidemiology
– Population coveredPopulation covered
– Healthcare settings coveredHealthcare settings covered
– Diagnostic procedures, treatments and Diagnostic procedures, treatments and interventions to be included or excluded.interventions to be included or excluded.
Must be a manageable size.Must be a manageable size.
Submit Draft Scope to NICESubmit Draft Scope to NICE
Consultation with stakeholders (4 wks)Consultation with stakeholders (4 wks)
Scope modifiedScope modified
Final scope (and comments) on websiteFinal scope (and comments) on website
Cannot normally be changed after thisCannot normally be changed after this . .
3. Workplan3. Workplan
NCC prepare a workplan setting out... NCC prepare a workplan setting out...
– GDG membershipGDG membership
– Development processDevelopment process
– TimescalesTimescales
– CostingsCostings
Agreed with NICE following negotiation.Agreed with NICE following negotiation.
The GDGThe GDG
Multidisciplinary participation is essential to Multidisciplinary participation is essential to ensure:ensure: Proper evaluation and interpretation of specialty-Proper evaluation and interpretation of specialty-
specific evidencespecific evidence
Relevance to the realities of everyday practiceRelevance to the realities of everyday practice
Ownership and cooperation of all stakeholderOwnership and cooperation of all stakeholder groupsgroups
Patient views and preferences are heardPatient views and preferences are heard
Role of GDGRole of GDG
Oversee, contribute to and agree ...Oversee, contribute to and agree ...
Clinical questionsClinical questions
Search strategySearch strategy
Consensus opinionConsensus opinion
Patient and carer involvementPatient and carer involvement
RecommendationsRecommendations
Final documents.Final documents.
4. Development4. Development
Define clinical questions (inform Define clinical questions (inform search)search)
Identify evidence (literature search)Identify evidence (literature search) Hierarchy of evidence:Hierarchy of evidence:
Systematic ReviewsSystematic Reviews
RCTsRCTs
Other well-designed studiesOther well-designed studies
Expert opinionExpert opinion
Assess & synthesise evidence.Assess & synthesise evidence.
Translate evidence into recommendationsTranslate evidence into recommendations
- - Graded A, B, C or Good practice point, Graded A, B, C or Good practice point, depending on strength of evidence depending on strength of evidence
Consensus opinion in important areas where there Consensus opinion in important areas where there is no evidenceis no evidence
- Formal consensus methods or GDG Formal consensus methods or GDG contributioncontribution
Prepare final guideline documentsPrepare final guideline documents- Full GuidelineFull Guideline- Algorithms where appropriate.Algorithms where appropriate.
5. Validation5. Validation
First Draft submitted to NICE - Full First Draft submitted to NICE - Full versionversion
4 weeks consultation – stakeholders4 weeks consultation – stakeholders Second draft prepared by NCC Second draft prepared by NCC 4 weeks consultation – stakeholders, 4 weeks consultation – stakeholders,
website, guidelines committee, NICEwebsite, guidelines committee, NICE Final draft prepared by NCCFinal draft prepared by NCC Ratified by NICE.Ratified by NICE.
6. Dissemination6. Dissemination
NCC publish full guidelineNCC publish full guideline
NICE publish short from and patient NICE publish short from and patient versionversion
Disseminated throughout the NHSDisseminated throughout the NHS
All versions available on NICE website.All versions available on NICE website.
7. Update7. Update
2-3 years depending on changes in the 2-3 years depending on changes in the available evidenceavailable evidence
Same or different development group.Same or different development group.
Dental recall: recall interval between Dental recall: recall interval between routine dental examinationsroutine dental examinations
Remit received from NICE in summer 2002Remit received from NICE in summer 2002 Scope drafted in early autumn and Scope drafted in early autumn and
stakeholder meeting held in November stakeholder meeting held in November 20022002
Guideline development group convened and Guideline development group convened and first meeting in January 2003first meeting in January 2003
Final meeting in January 2004Final meeting in January 2004 First draft submitted to NICE in February First draft submitted to NICE in February
Who is involved in the dental Who is involved in the dental recall guideline?recall guideline?
Systematic reviewing staff:Systematic reviewing staff:– NCC-ACNCC-AC– Cochrane Oral Health GroupCochrane Oral Health Group– International Centre for Evidence Based International Centre for Evidence Based
Periodontal HealthPeriodontal Health
Guideline Development GroupGuideline Development Group
Dentists and dental hygienists representing Dentists and dental hygienists representing NHS and mixed practicesNHS and mixed practices
PeriodontologistPeriodontologist ResearchersResearchers Patient representativesPatient representatives Groups represented include:Groups represented include:
– BDA, FDS, FGDP, Centre for Evidence Based BDA, FDS, FGDP, Centre for Evidence Based Dentistry, British Society of PeriodontologyDentistry, British Society of Periodontology
TimelinesTimelines
First draft out for stakeholder consultationFirst draft out for stakeholder consultation– 2424thth February to 23 February to 23rdrd March 2004 March 2004
Second draft our for consultationSecond draft our for consultation– 33rdrd May to 31 May to 31stst May 2004 May 2004
PublishedPublished– September 2004September 2004