Developing Evidence-Based Guidelines for Health Protection: An Overview

1. Developing Evidence-Based Guidelines for Health Protection - An overview of the process - A COMMON APPROACH ALEX SANCHEZ-VIVAR

2. Moriarty: “Everything I have to say has already crossed your mind.” Sherlock: “Probably my answer has crossed yours.”

3. 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

4. 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.

5. 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

6. Why does evidence-based practice matter to us?

7. 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

8. 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

9. Definition of EBM • “The integration of best research evidence with clinical expertise and patient values.” Sackett DL et al; Churchill Livingstone, 2000

10. 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 one’s clinical expertise and the individual patient • Evaluate Sackett DL. EBM: how to practice and teach EBM. Churchill Livingstone 2000

11. Critique of EBM • De-emphasizes patient values • Doesn’t account for individual variation • Devalues clinical judgment • Leads to therapeutic nihilism

12. 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

13. 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) Jenicek M. J Epidemiol 1997;7:187-97

14. Strong evidence supports that… • “teaching is not effective on Friday afternoons”

15. Interpretation of “communications” • Trust? – source • Evidence – Identified and synthesised? • Recommendations link with the evidence? • Validation  improve practice?  implementation

16. 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)

17. 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.

18. 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

19. 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 1995< 274> 570-574

20. 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

21. 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

22. 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

23. 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

24. Potential benefits for healthcare systems Improve efficiency Optimise value for money Demonstrate adherence to guidelines may improve public image

25. 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

26. 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

27. NICE SIGN GUIDELINES HPS GUIDELINES Development Proposal SCOPE THE GUIDELINE ORGANISATION OF GUIDELINE DEVELOPMENT PREPARE THE WORKPLAN TOPIC SELECTION & SCOPE SELECTION OF GUIDELINE TOPICS COMPOSITION OF THE GUIDELINE DEVELOPMENT GROUP FORM THE GUIDELINE DEVELOPMENT GROUP (GDG) AND MEETINGS COMPOSITION OF THE GUIDELINE DEVELOPMENT GROUP IDENTIFICATION & EVALUATION OF EVIDENCE FORMULATE THE CLINICAL QUESTIONS SYSTEMATIC LITERATURE REVIEW FORMATION OF RECOMMENDATIONS & GRADING IDENTIFY THE EVIDENCE FORMATION OF RECOMMENDATIONS REVIES AND GRADE THE EVIDENCE DEFINE RESOURCE CONSEQUENCES CONSULTATION AND PEER REVIEW CREATE GUIDELINE RECOMMENDATIONS CONSULTATION & PEER REVIEW CONSULTATION DRAFTS AND PEER REVIEW PRESENTATION AND DISSEMINATION EDIT & PUBLICATION FINAL GUIDELINE LOCAL IMPLEMENTATION FORMULATION OF AUDIT & PEER REVIEW REVIEW AND UPDATE WITHIN AND AGREED TIMEFRAME AUDIT AND REVIEW CPD Scottish Intercollegiate Guidelines Network. SIGN 50: A Guideline developers’ handbook, Edinburgh, March 2004 National Institute for Clinical Excellence. Guideline Development Methods. London, Feb 2004 GUIDELINE DEVELOPMENT PROCESS Looking at how

28. 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

29. Health Protection Network (HPN) Guideline Development Framework

30. 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

32. “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

33. 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

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

36. 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

37. Challenges in grading recommendations • Intrinsic to the nature of HP (2 of 2) E-B Guidelines for Health Protection no no some D GPP ?

38. 4. Key Considerations • Good understanding of what’s 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)

39. Thanks Alex Sánchez-Vivar alex.sanchez-vivar@nhs.net “In order to move forward, we need two legs: action and reflection” Gaudi

41. 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

42. 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”