PRACTICE GUIDELINES ORIENTATION

1. PRACTICE GUIDELINES ORIENTATION Melissa Brouwers, PhD mbrouwer@mcmaster.ca Capacity Enhancement Program

2. Objectives • To understand different guideline philosophies and models. consider what philosophy/model fits with your context • To understand the guideline development cycle. consider what steps are relevant and can be applied to your context • To understand the value of social engagement. consider social engagement within your context (who should be involved? how? when?) • To understand some of the challenges

3. Practice guidelines: origins ~ Clinical Practice Guidelines (CPGs) ~ systematically developed statements to assist provider and patient decisions about appropriate health care for specific clinical circumstances • systematic vs. arbitrary • statements to assist • enabling documents vs. rules to dictate or formulaic protocols • range of stakeholders

4. Practice guidelines: evolution How can we help health care providers make better cancer care decisions with their patients? How can we help administrators make better decisions regarding how the cancer care system is organized in their center, hospital or region? How can we help government make better decisions that will ensure the most effective cancer care strategies are available to a population?

5. Practice guidelines: evolution Guidelines for Cancer Control: Systematically developed statements, informed by research evidence, values and local/regional circumstances to assist fair decisions and judgments about cancer control at the clinical, management and policy levels.

6. Practice guidelines: example Laparoscopic Surgery of the Colon Clinical Question Can laparoscopic surgery be recommended as an alternative to conventional open surgery for patients with stages I, II, or III colon cancer (not rectal cancer) based on a comparison of outcomes? Primary outcomes of interest include survival, recurrence, and adverse event rates. Secondary outcomes of interest are operating time and time until hospital discharge.

7. Practice guidelines: example Laparoscopic Surgery of the Colon Professional Practice Question What is the recommended experience and training for surgeons who perform laparoscopic surgeries for cancer of the colon? Institutional and Organizational Question What are the recommended criteria for institutions performing laparoscopic surgeries for cancer of the colon? Of interest: recommended surgical volumes, clinical team, equipment

8. Philosophies of development Evidence-based > Consensus >Expert Opinion

9. Philosophies of development evidence-based > what it means The explicit, conscientious and judicious use of the best available evidence from healthcare research in the management of individual patients and in program planning.

10. Philosophies of development • evidence-based > strengths • better estimates of “truth” • transparent • defensible • credible • reproducible

11. Philosophies of development evidence-based > in action • formal and explicit methods & philosophy • for working with healthcare research • locating • evaluating • selecting • synthesising • analysing • interpreting • reporting • evaluating • informing recommendations

12. Philosophies of development evidence-based > limitations • decisions regarding quantitative versus qualitative synthesis • juxtaposing clinical benefit against clinical harm • generalizing from study conditions to “real life” • values of patient, society and professionals • context issues: resources, systems, access resource intensive and slow

13. Philosophies of development expert opinion > strengths credible and knowledgeable people able to contextual evidence based on experience consensus approach > strengths formal methodologies to reach agreement (delphi technique) several knowledge sets represented

14. Philosophies of development • expert opinion and consensus > limitations • not a methodology • evidence is implicit • threat of conflict of interest • what expertise do you select • clinical? methodological? • can not replicate process • no explicit basis for clinical recommendations

15. An Evidence-based Approach Incorporating • Consensus from Experts • an integrated philosophy • provides a formal and explicit methodology • ensure appropriate content experts are at the table • opportunity to interpret the evidence and judge its applicability in specific clinical situations, systems, and contexts social and scientific engagement

16. Philosophies of development integrated philosophy > in action creating cultures, fostering communities of practice, and enhancing capacity ….. receptive to evidence ….. understand evidence ….. apply evidence to improve cancer control Evidence-based advice documents are the points around which the culture can evolve and be sustained.

17. Philosophies of development checking in what is the philosophical model in your context? is there value in making it explicit? what model(s) resonate(s) and do(es) not resonate(s) with you?

18. Evidence-based Advice Cycle adapted from Guideline Development Cycle (Browman et al.) elements common across many guideline programs and initiatives generalizable recognition of science/methods and social engagement components

19. PEBC: Evidence-based Advice Cycle Evidence-based Advice Panel topic selection: explicit question method selection: systematic review, environmental scan, adaptation, consensus • draft report: • evidence • expert interpretation and consensus • draft reccs monitoring updating implementation updated reccs • external review: • clinicians • administrators • system & policy dissemination publication • final report: • evidence • expert interpretation and consensus • description of external review • final reccs

20. Cancer Care Ontario Performance Improvement Model • Data/Information • incidence, mortality, • survival analysis • indicator development • expert input • Knowledge • clinical guidelines • policy advice • synthesis • planning • Transfer • publications • practice leaders engaged • policy advice • public reporting • Performance Management • institutional agreements • quarterly review • quality - linked funding • clinical accountability

22. Stakeholder Engagement • aim to have users of knowledge be the developers of knowledge • enhance capacity • evidence-based or evidence-informed model = norm • contextualize evidence properly • increase acceptance and adoption of recommendations • create an accountability mechanism

23. Challenges - sustainability How can we ensure ongoing participation of stakeholders in the process (panels, review)? What are the implications of stakeholder fatigue? To what extent do we have biased participation? Who should be engaged? At what time? For what purpose?

24. Where does the guideline sit within the political landscape? What is the level of integration with policy, funding and administrative decisions NHS vs. PEBC vs. Region A vs. Hospital B Government is responsive to public. Sometimes worlds do not always align. Challenges – impact of political landscape

25. Methodological advancement: the great divide between an academic lens and service lens. Rigorous, credible, transparent, replicable methods that are sustainable, affordable and make a meaningful impact. Challenges – rigour and pragmatism

26. Key Take Home Messages think critically about your philosophy integrate the social and the scientific balance both with the realities of your enterprise do not let the ideal stop the good Questions? Comments? Feedback?