The International Guidelines Network

1. The InternationalGuidelines Network Hans V. Hogerzeil, MD, PhD, FRCP Edin Essential Drugs and Medicines Policy WHO, Geneva ICIUM-2, March 2004

2. G-I-NBackground Council of Europe, 2001 recommended promoting international networking between organisations producing evidence-based health information. June 2002; idea of an International Guidelines Network discussed at CPG 2002 Symposium in Berlin. June - October 2002; working group of 11 organisations from 8 countries developed a draft constitution for The Guidelines International NetworkG-I-N. November 2002;G-I-NFounding Committeeconsent on constitution and establish executive board.

3. Agency for Quality in Medicine ÄZQ, D Association of Scientific Medical Societies AWMF, D Basque Office for HTA OSTEBA, E Belgian Center for Evidence based Medicine, B Berlin Chamber of Physicians, D Center for Health Policies and Services, ROM Center for Reviews & Dissemination York, UK Clinical Epidemiology Center Lausanne CepiC, CH Danish Center for Evaluation and HTA DACEHTA, DK Directorate for Health and Social Affairs, NO Directorate for Health Iceland, ISL Dutch Association of Comprehensive Cancer Centres, NL  Dutch College of General Practitioners, NL Dutch Institute for Healthcare Improvement CBO, NL Estonian Health Insurcance Fund, EE evidence.at -Austrian Ass.for Quality in Healthcare, A Finnish Medical Society Duodecim, FIN Finnish Office for HTA FINOHTA, FIN Flemish College of General Practitioners WVVH, B German Federal Institute for Quality Assurance, D German Joint Federal Committee, D HTA Unit, Ministry of Health Malaysia, MAL Institute for Quality in Healthcare, POR Italian Evidence-Based Medicine Group GIMBE, I J.Briggs Inst.for Evid.Based Nursing&Midwifery, AUS G-I-N Organisational Members Josep Laporte Library Foundation, Barcelona, E Nat.Agency for Accred., Eval in Healthcare ANAES, F Nat. Board of Health and Welfare (Socialstyrelsen), S National Federation of Cancer Research Centres, F National Institute for Clinical Excellence NICE, UK National Institute of Clinical Studies NICS, AUS National Kidney Foundation, USA New Zealand Accident Compensation Corporation ACC, NZ New Zealand Guidelines Group NZGG, NZ Polish Institute for EbM, PL Program in Evidence-based Care, Cancer Care Ontario, CDN Regional Health Agency Emilia-Romagna, I Royal College of Nursing Institute, UK Royal College of Surgeons in Ireland RCSI, IRL Royal Dutch Ass. of Physiotherapy KNGF, NL Scottish Intercollegiate Guidelines Network SIGN, UK Slovene Guidelines Group, SLO Sowerby Centre for Health Informatics at Newcastle, UK Spanish Network for Research on Guidelines, E Swiss Medical Association FMH, CH The AGREE Collaboration, INT TRIMBOS Institute, NL Turkish MoH – School of Public Health (TR) U.S.Agency for Health Research & Quality AHRQ, USA World Health Organisation Geneva WHO, INT 50 Organisations 26 countries (March 2004)

4. Mission Statement “G.I.N. seeks to improve the quality of health care by promoting systematic development of clinical practice guidelines and their application into practice, through supporting international collaboration.”

5. G-I-N Goals • Information sharing, knowledge transfer, collaborative working • Improvement, harmonisation of methodologies for CPG development, dissemination, implementation, evaluation • Support of research • Coordination with other health care quality initiatives

6. G-I-N Working Groups • Background documentation, development tools, training materials • Grading harmonization • Guideline programme information • Publications and website • Workshops and conferences 

7. Remit / ToR* Key Questions Checklist Checklist Checklist Checklist Checklist Checklist Literature Search Checklist Checklist Checklist Checklist Checklist Checklist Evidence Table Evidence Table Evidence Table Considered Judgement Considered Judgement Considered Judgement Guideline recommendations The guideline process *ToR: Terms of referance

8. SIGN/NICE –share evidence tables • SIGN and NICE each appraise 50% of the evidence and produce individual evidence tables • Both exchange these evidence tables, so each group has a summary of 100% of the evidence but has only had to appraise 50% of it • The judgement process is unique to each guideline developer • SIGN and NICE produce separate guidelines

9. SIGN/BTS Collaboration • Until 2001, the UK had 4 distinct but complementary asthma guidelines • One produced by the British Thoracic Society (UK wide distribution but influenced by membership of BTS) • Three produced by SIGN (distribution theoretically restricted to Scotland) • 1999 – BTS and SIGN agreed to collaborate on the production of a single asthma guideline for UK wide distribution

10. SIGN/BTS – joint benefits • Used SIGN methodology • with UK wide rather than Scottish representation • Shared costs • Used BTS clinical contacts and distribution networks • Guideline produced as a supplement to Thorax • Joint Guideline has a high profile throughout the UK

11. Management of Colorectal Cancer Define guideline remit and key questions A national clinical guideline – July 2003 Find and appraise potential source guidelines Consider updating / adaptation required Searchingand systematic review of additional evidences Critical appraisal of additional evidences Synthesise results and update evidence summaries FORM RECOMMENDATIONS Slovene Adaptation Process • This guideline is based on an evidence-based guideline in development by the Scottish Intercollegiate Guidelines Network (SIGN). • This source guideline has been adapted to include Slovenian data and to reflect the context of organisation and delivery of care to patients with colorectal cancer in Slovenia, as well as including updated research and evidence following a systematic literature search completed with the assistance of SIGN.

12. Findings (1) • The systematic review component of the guideline development process can be shared between guideline developers • Variation in grading systems make the synthesis of evidence appraised in different countries difficult - but not impossible. There needs to be a standardised way of developing and updating evidence tables • Removing the evidence search and appraisal places greater importance on the “considered judgement” part of the process

13. Findings (2) • Locally adapted guidelines need to explicitly consider workload and cost implications in their local setting • Collaboration in guideline development can significantly increase the quality and efficiency of guideline development work. • Sharing programme information • Standardized development of evidence tables • Adapting or endorsing guidelines • There is a great potential to create ‘living guidelines’ that can tap into updated evidence tables – such as asthma

14. Conclusion • Collaborative initiatives have to date been largely opportunistic • The potential benefits are sufficiently great that guideline organizations should now be actively seeking collaboration • GIN can help in standardizing methods and exchanging evidence tables

15. World Health Organisation Department of Essential Drugs and Medicines Policy 1211 Geneva, Switzerland Fax 41-22-7914167 Web Site: http://www.who.medicines/ Documentation Centre: darec@who.int