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European Best Practice Guidelines

European Best Practice Guidelines. James Tattersall. Background. Process commissioned by EDTA-ERA in 1998 KDOQI, CARI, UK renal guidelines already published Considerable guideline activity underway “Expert groups” Transplant (2000, 2002) HD (2002, 2007) PD (2005) Anaemia (1999, 2005).

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European Best Practice Guidelines

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  1. European Best Practice Guidelines James Tattersall

  2. Background • Process commissioned by EDTA-ERA in 1998 • KDOQI, CARI, UK renal guidelines already published • Considerable guideline activity underway • “Expert groups” • Transplant (2000, 2002) • HD (2002, 2007) • PD (2005) • Anaemia (1999, 2005)

  3. Co-operative initiatives • K/DOQI • Bone metabolism 2004 • Hypertension in CKD 2004 • CVD in dialysis 2005 • Anemia 2006 • KDIGO • Classification/ definition CKD • Hep C • Bone/mineral metabolism

  4. Organisation facilitating guidelines • Logistical and secretarial • Baxter • Fresenius • Hoffman-La Roche, Amgen, Vifor, Ortho-Biotech • Literature search and evidence grading • Cochrane (HD) • Thomson Gardiner-Caldwell (Anaemia) • Collection of feedback and dissemination of guidelines • EDTA-ERA

  5. Funding sources • Baxter (PD) • Fresenius (HD) • Hoffman-La Roche (Transplant, Anaemia) • Amgen (Anaemia) • Ortho Biotech (anaemia) • Vifor (anaemia)

  6. How guidelines relate to healthcare systems in area • Europe is diverse • 30 + countries • Mixture of models (socialised, insurance-based) • Mixture of languages. • Differences between levels in healthcare funding. • ‘New’ ex-soviet empire European countries inherited broken systems. • At least for dialysis, convergence was surprisingly rapid. • No attempt to include cost-benefit in the guidelines

  7. Selection and prioritisation of guideline topics • No formal process • Decided by the expert groups (HD, PD, Transplant) • Composition of group • Existing guidelines • Availability of evidence • Considered to be important

  8. Selection of expert groups • Invited by the ERA-EDTA council. • No formal selection process • European experts on the guideline topic • No more than 1-2 per country in each group. • Initially only nephrologists • HD group invited one dietician, one radiologist and one surgeon for 2nd part.

  9. Methodology • Delegated to expert groups. • Division into sub-groups (3-4 members) • Formulation of important questions • Generation of key words • Literature search performed by Cochrane • All literature graded by Cochrane • All literature scored by expert group. • Each paper scored by at least 2 members. • Modified READER system (with elements of GRADE) used to score papers.

  10. Methodology (2) • Randomly selected papers presented to group and the scores challenged by whole group. • Low-scoring papers automatically rejected • Reader score includes relevancy. • Rejected papers retained as part of the guideline audit. • Guidelines formulated by sub-groups. • Guidelines presented and circulated to entire group. • All guidelines signed-off by each group member.

  11. Methodology (3) • External expert reviewers selected • Non-nephrologists • Non-European • Draft guidelines submitted to • Reviewers • ERA-EDTA membership • Selected international nephrology societies (ISN, ASN, CSN, CARI) • All European national associations.

  12. Disseminations and implementation • Draft guidelines, responses and proposed amendments presented at ERA-EDTA conference 2006 • Final versions published 2007 • Published in NDT • ERA-EDTA website • Impact to be assessed by QUEST projects. • Adequacy of HD

  13. strengths • Formal, independent selection of evidence. • Formal, transparent scoring of papers. • Consultation at late stages • Ongoing study to assess impact (QUEST) weaknesses • Commercial funding • Qualification/selection of expert groups. • No patient, manager or nurse representation. • Inconsistent style, format, terminology • No consideration of guideline lifecycle • No consultation at early stage • Prioritisation • Questions asked • What the guidelines are trying to achieve not clearly stated.

  14. Future outlook • ERA-EDTA have a responsibility to maintain, update, withdraw or correct existing guidelines. • Impact of existing guidelines to be monitored by QUEST • ERA-EDTA council have decided that the Association should remain involved in new guideline development. • The form of this involvement has not yet been decided. • First EBPG meeting January 2008

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