Knowledge (evidence) translation and utilisation, leading to improved patient outcome

1. Knowledge (evidence) translation and utilisation, leading to improved patient outcome ‘A whole healthcare systems approach’ Ian Bullock Jill Parnham

5. NCGC • Commissioned by DH & NICE • 20+ guidelines / QS in development • Budget of £4.56 million (2,818,008 OMR) • ~70 staff – specialist expertise EMB • Inter related work with RCP Clinical Standards

6. NCGC UK STAKEHOLDERS context Patients Professions NHS Industry

7. NCGC Vision that is: • Focussed on quality (Quality Standards) • Patient centred (High political priority) • Clinically driven (Professionally important) • Flexible (Diverse work programme) • About valuing people (Always about people) • Promoting continuous improvement(With growth inevitably comes increased responsibility)

8. The quality spiral • Largest EB guideline centre in world • Commissioned by DH / NICE • 14 guidelines in development, rolling programme • XXX scoping • Full guideline takes XXX months

9. National Clinical Guideline Centre • Formed on April 1st 2009 • Merger of 4 National Collaborating Centres - Primary Care (RCGP) - Chronic Conditions (RCP) - Nursing and Supportive Care (RCN) - Acute Conditions (RCS) • Hosted by Royal College of Physicians

10. Guideline Development • Multidisciplinary group • Supported by technical team (researchers; health economists; information scientists and project managers) • Technical team are members of the group with voting rights

11. Developing clinical guidelines • Scoping: Identify and refine the subject area • Convene multi disciplinary guideline development groups including patients/carers • Develop clinical questions: process started • Obtain and assess the evidence about the clinical questions • Analyse and present evidence to GDG • Translate the evidence into recommendations (clinical guideline) • Arrange external review of the guideline

12. Mark Twain • ‘Synergy — the bonus that is achieved when things work together harmoniously.’

13. Answering the clinical questions • Each recommendation needs to relate to a question • Each question has to be addressed with a systematic review of the evidence • Each systematic review requires • A question protocol listing inclusion/exclusion criteria • A comprehensive literature search • Each study reviewed to be quality assessed using NICE forms* • Each included study to have data extracted into an evidence table • Each outcome from each question to be synthesised into a meta-analysis (where possible)* • The collated estimate for each outcome to be assessed using GRADE* • Results written up in the guideline

14. Types of questions • Aetiology/causation • Diagnosis/screening • Prognosis • Effectiveness (therapy, clinician, organisation) • Cost-effectiveness • Harm • Variation in practice • Equity • Experience and meaning

15. General structure of a clinical question • The acknowledged structure is known as PICO • Population • Intervention (or exposure for prognosis) • Comparison (optional) • Outcome

16. PICO Structure – effectiveness example

17. NICE principles – include social value judgements • Need evidence to recommend an intervention (can make ‘research only’ recommendations) • Clinical and cost effectiveness • Good use of resources • Can make recommendation for a subgroup of population if clear evidence for effectiveness • Involve and respond to stakeholders • Equalities • Transparency

18. How evidence presented to GDG • Details of study – where, population groups, interventions etc • Quality assessment – checklists/GRADE • Results – varies e.g. narrative, forest plots • Interventions – GRADE profiled • Meta-analysis where possible • Health economic modelling outcomes ‘evidence’

19. Why consider cost-effectiveness? • The NHS does not have enough resources to do everything • If it spends more on one thing, it has to do less of something else • Could we do more good by spending money differently? • Prioritise interventions with a high health gain per £ spent

20. Why are recommendations difficult in evidence based guidelines? • No evidence • Poor evidence • Doesn’t answer the question • Wrong patient group • Wrong comparator • Wrong outcome

21. Options when evidence poor/no evidence • Extrapolate if possible (indirect evidence) • Expert group discussion (informal consensus) • Vote • Formal consensus decision making • Transparency and acknowledgement • No recommendation

22. Guideline Development Timeline

23. NICE (NCGC) and Quality Initiatives • 2000 -2006 • Focus on guidance, not indicators or standards • Clinical Guidelines; Public Health Guidance and Technology Appraisals • Developed audit tools directly based on NICE guidelines • 2008 • Labour Government’s Next Stage Review • Expanded role for NICE in Quality Indicator Development • NICE-managed QOF for general practice • NICE to develop Quality Standards • 2010 (July) • Coalition Government’s Health White Paper • NHS Outcomes Framework • NICE Quality Standards seen as central to delivering this

24. What are Quality Standards? • Quality statements • Descriptive statements (5 to 10) of the critical infra-structural and clinical requirements for high quality care as well as the desirable/expected outcomes • Key points on care pathway • Quality measures • Structure, process (and outcome) measures • “High Level” Quality Indicators • Use at local level as audit criteria • Inform subsequent national indicator development

25. What are Quality Standards? • Audience descriptors • A description of what the quality standards mean for different audiences • Service providers • Health and Social Care Professionals • Commissioners • Patients

26. What is the purpose of Quality Standards? • To make it clear what high quality care is by providing definitions of clinical and cost-effective care • To support benchmarking of performance • To provide information to patients and the public about the quality of care they can expect

27. NICE Quality Standards programme • Aims • To develop Quality Standards for topics selected by the National Quality Board (NQB)/ NHS Commissioning Board on an annual basis • To offer clarity about what high quality care looks like across 3 dimensions of quality ensuring: • Patient care is effective • Patient care considers patient experience • Patient care is safe • To develop a comprehensive set • 150 to be developed over 5 years

28. Current Work Programme NCGC produced

29. Overview of Quality standards development

30. Evidence Source • Policy Drivers • Audit evidence on current care Quality Standard NICE quality standards • NICE quality standard • Quality statements • Measures Clinical Guideline Recommendations - NHS Evidence Accredited Sources • Key Department of Health and other documents • National Clinical Audits • - Current clinical practice (areas requiring improvement)

31. NICE Stroke Quality Standard • Scope of Quality Standard: • Care provided to adult stroke patients • diagnosis and initial management, acute phase care, rehabilitation and long-term management • Policy context: • Department of Health “National Stroke Strategy” (2007) • Department of Health “Reducing Brain Damage: faster access to better stroke care” (2005) • Key development sources: • Royal College of Physicians “National Clinical Guideline for Stroke” (2008) which incorporates NICE CG68 Diagnosis and initial management of acute stroke and transient ischaemic attack (2008) • National Sentinel Audit for Stroke (2000 – ongoing)

32. Example quality statement for stroke • In a high quality service for patients with stroke ... • Patients with acute stroke receive brain imaging within 1 hour of admission if they meet any of the indications for immediate imaging (QS2) • Relevant CG recommendation • Brain imaging should be performed immediately (within 1 hour) for people with acute stroke if any of the following apply …

33. Example of quality measure for stroke • Structure:Evidence of local arrangements to ensure patients with acute stroke receive brain imaging within 1 hour of arrival at the hospital if they meet any of the indications for immediate imaging. • Process: Proportion of patients with acute stroke who meet any of the indications for immediate imaging who have had brain imaging within 1 hour of arrival at the hospital. [Numerator & Denominator defined]

34. What the quality statement means for each audience – stroke example • Service providers ensure facilities and protocols are available for patients to receive brain imaging within 1 hour of arrival at the hospital if they meet any of the indications for immediate imaging. • Health care professionalsensure that patients under their care with acute stroke receive brain imaging within 1 hour of arrival at the hospital if the criteria for immediate imaging are met. • Commissionersensure that services they commission enable patients to receive brain imaging within 1 hour of arrival at the hospital if they meet any of the indications for immediate imaging. • Patientswith acute stroke with any of the indications for immediate brain imaging can expect to receive this within 1 hour of arrival at the hospital.

35. Data Source • Structure:Local data collection. • Process:Trusts can collect data via the Sentinel Stroke Audit, Hospital Episode Statistics (HES) data and through local data collection. • There exist existing quality assured indicators • Sentinel Stroke Audit CV02 • Proportion of stroke patients given a brain scan within 24 hours of stroke • DH WCC Assurance Framework Acute 36 • Percentage of stroke admissions given a brain scan within 24 hours

36. How will quality standards be used? Used to drive up the quality of health care • For use by: • patients, the public, health and social care professionals, commissioners and service providers • Can be used in: • commissioning, payment mechanisms and incentives schemes such as CQUIN, Quality Accounts and Care Quality Commission special reviews

37. Measurement is crucial and can be linked to consultant appraisal

38. Stroke quality spiral • Epidemiology • Policy context • Setting standards • Measuring standards • Improving quality of clinical care

39. UK stroke epidemiology

40. Stroke • Stroke is one of the top three causes of death and the largest cause of adult disability in England, and costs the NHS over £3 billion (1,854,274,200 OMR) a year.

41. Stroke • In 2008-09, the direct care cost of stroke was at least £3 billion annually, within a wider economic cost of about £8 billion (4,945,200,233 OMR). • Without preventative action, there is likely to be an increase in strokes as the population ages.

42. Stroke • One in four people who have a stroke die of it. • There are approximately 110,000 strokes and 20,000 TIAs per year in England. • 300,000 people are living with moderate to severe disabilities as a result of stroke.

43. National stroke picture

44. NICE Acute Stroke Guideline • Took 24 months to develop • 18 experts plus technical team • Rigorous and systematic methodology • Published 2008 • Looked at thousands published papers • Based recommendations upon 200 key papers • Made 62 EB recommendations

45. Stroke care pathway

46. Stroke care pathway • ‘Time lost is brain lost’ • Pathway derived from the evidence based NICE guideline

50. Guidelines • The NICE guideline (July 2008) covers interventions in the acute stage of a stroke (‘acute stroke’) or transient ischaemic attack (TIA). • Most of the evidence considered relates to interventions in the first 48 hours after onset of symptoms, although some interventions up to 2 weeks are covered.