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Towards EBCPGsImplementation
for PhysiciansDr. Yasser S. AmerMBBCh, MPed, MHCI, CPHQ
Coordinator, KSUMC-Wide CPG Steering CommitteeCoordinator, Research & Development, Quality Management Dept.
6th Residents Professional Development CourseCollege of Medicine, King Saud University
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بســـــم الله الرحمـــــن الرحـــــيم
In the name of Allah. Most Gracious, Most Merciful
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Learning objectives• CPG Definitions & concepts• How to scout for EBCPGs?• How to appraise CPGs (standards)?• Develop or adapt CPGs?• CPG implementation?• KSUMC CPG program• How to access and use KSUMC CPGs ?• What is your role as a physician?
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Evidence-Based Medicine (EBM) Movement: Not new!
• 865–925 Al-Razi (Rhazes)1st need for experiments, comparisons in clinical studies
• 981–1037 Ibn Sina (Avicenna)test effect of drugs on humans not animals only
• 1987 David M. Eddy, MD, PhD ‘EB’ in EBCPGs, policies in workshops, manual
• 1992 Gordon Guyatt, MD‘EBM’ term in JAMA
• 1996 David Sackett, MD‘EBM’ definition in BMJ
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The Georg Ebers Papyrus.
Found in Egypt in the 1870s,the Ebers Papyrus contains prescriptions written in hieroglyphics formore than 700 remedies, including this one for an acute asthma attack.From: University of Leipzig
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The EBM Triad
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Definition: (old)
“Systematically developed statements to assist
practitioner and patient decisions about appropriate
health care for specific clinical circumstances”
(IOM 1990) Increasing international interest in the development
& implementation of CPGs!
Clinical Practice Guidelines (CPGs)
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CPGs Definition (New)
“Statements that include Recommendations
intended to optimize patient care that are
informed by a Systematic Review of evidence and
an assessment of the benefits and harms of
alternative care options”Committee on Standards for Developing Trustworthy
CPGs (IOM-AHRQ 2011)
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WhyDo we need CPGs?
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Rationale for CPGs•Worldwide concerns about:- ▫Unexplained variation/ variability in clinical practice
▫Rising healthcare costs
▫Exponential growth of health information• Aim of CPGs:-
To facilitate more consistent, effective and efficient practice and improve health outcomes for patients
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WhoNeeds CPGs?
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Stakeholders (TEAM)•Physicians•Nurses•Pharmacists•Decision makers•Patients•Public
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HowDo we react to CPGs?
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Read
AdoptAdapt
Develop
CPGs?
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Different Options to deal with CPGAdoption
Adaptation
Rejection
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Adaptation of CPGsIs the systematic approach to the endorsement
and/or modification of a guideline(s) produced in one cultural and organizational setting for application in a different context. Adaptation may be used as an alternative to de novo guideline development, e.g., for customizing (an) existing guideline(s) to suit the local context.
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Types of CPGsThe Role of CPGs in Health Care Reform (Rosoff AJ 1994)CPGs are basically of two types:-
1. Quality-enhancing CPGs are primarily intended to improve medical outcomes, often by increasing the amount of care given.
2. Cost-reducing CPGs are oriented toward cutting costs, generally, by limiting the amount of care given.
http://www.upenn.edu/ldi/issuebrief1_2.html
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Types of CPGs (cont’d)
1.Evidence-Based CPGs (evidence-based methodology)
2.Consensus/ expert-based CPGs
Which type do you think is better?
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The EBM Triad
EVIDENCE PYRAMID ?
2205/02/2023
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Evidence Pyramid
SR
RCT
Cohort
Case control
Case series
Case report
Expert opinion
I
II
III
IV
A
B
C
Leve
ls o
f Evi
denc
eG
rades of Recom
mendations
MA
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How to search for CPGs on the Web?
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CPGs on the Web
Producers Finders
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Guideline Producers• Specialized (professional) societies• Healthcare Organizations• Governmental (National) organizations: NICE, SIGN,
NHMRC, ,etc.• International organizations
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Organization NameCountry
URL Producer Finder FREE PAID
Guidelines International Network (G-I-N) Int’l http://www.g-i-n.net F √ √
World Health Organization (WHO) Int’l http://www.who.int/topics P √
National Institute for Health & Clinical Excellence (NICE) UK http://www.nice.org.uk/page.aspx?
o=ourguidance P √ √
Scottish Intercollegiate Guidelines Network (SIGN) Scotland http://www.sign.ac.uk/guidelines/index.html P √
New Zealand Guideline Group (NZGG) NZ http://www.nzgg.org.nz P √
Registered Nurses Association of Ontario (RNAO) Canada http://www.rnao.org P √
National Guidelines Clearinghouse (NGC) USA http://www.guidelines.gov F √
US National Library of Medicine, National Institutes of Health (PubMed) USA http://www.ncbi.nlm.nih.gov/pubmed
OR http://www.pubmed.gov F√
(Abstracts)
√(Full Text
)
Institute for Clinical Systems Improvement (ICSI) USA http://www.icsi.org/knowledge/ P √
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CPG Producers:National Agencies
NICENational Institute for Health & Clinical Excellencewww.nice.org.uk
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NICE Guidance
>132 CPGs
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SIGNScottish Intercollegiate Guidelines Networkwww.sign.ac.uk
> 12 CPGs
CPG Producers: National Agencies
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N.H.M.R.C.
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WHO
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Societies: PEDIA AAP
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MED ACP
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FM/PC AAFP
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SURG RCS
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SURG BPGS
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OBS-GYNE RCOG
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CARDIO ESC
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PSYCH The Maudsley Hospital
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PSYCH APA
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ORTHO AAOS
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CPG Finders
AHRQ-NGCNational Guideline
Clearinghousewww.guidelines.gov
> 408 CPGs05/02/2023 44
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Shaikh Bahamdan’s Research Chair for Evidence-Based Health Care & Knowledge Translation
Member of G-I-N since Oct. 2009Free access to International CPG Library of G-I-N
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://http . . . / /c ksu edu sa ebhc en
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http://ebhc.ksu.edu.sa/gin/index.html
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EBSCO DynaMed & DynaMed Plus
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Guideline Central
CPG Finders
PubMedUS National Library of Medicine
National Institutes of Health (NIH)
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Standards for high quality CPGsIOM 2011 – G-I-N 2012
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IOM 2011: 8 Standards for Developing Trustworthy CPGs
1. Establishing transparency.
2. Management of conflict of interest (COI).3. GDG composition.
4. CPG – SR intersection.
5. Establishing [E] foundations for and rating strength of [Rs]. (i.e. E – Rs link)
6. Articulation of [Rs].7. External review.
8. Updating.
05/02/2023 56Date of download: 8/19/2014
From: Guidelines International Network: Toward International Standards for Clinical Practice Guidelines
Ann Intern Med. 2012;156(7):525-531. doi:10.7326/0003-4819-156-7-201204030-00009
Copyright © American College of Physicians. All rights reserved.
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12
3
456
78
91011
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How to assess of the quality of any CPG?
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Assess CPG qualityAGREE II Instrument • 23 items in 6 domains• 7 point response scale• 6 Domain scores• Overall assessment &
recommendations for use
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23 Items in 6 DomainsUSER’S MANUAL page 7
DOMAINS No. of Items
1 Scope & Purpose 3
2 Stakeholder Involvement 3
3 Rigour of Development 8
4 Clarity & Presentation 4
5 Applicability 3
6 Editorial Independence 2
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DOMAIN 1. SCOPE AND PURPOSE
1. Objective(s)2. Health Question(s)3. Target population
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4. Guideline group5. Patient preference 6. Target users
DOMAIN 2. STAKEHOLDER INVOLVEMENT
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7. Systematic methods for E search8. Selection Criteria of E9. Strengths & Limitations of E10. Methods of Rs formulation 11. Benefits , side effect and risks in Rs12. Evidence Links (Gs of Rs – LoE)13. External Review 14. Update Procedure
DOMAIN 3. RIGOUR OF DEVELOPMENT
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DOMAIN 4. CLARITY OF PRESENTATION
15. Rs are specific 16. Options for management 17. Recommendation identifiable
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DOMAIN 5. APPLICABILITY
18. Facilitators & barriers 19. Tools20. Resource implications21. Monitoring /audit criteria
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DOMAIN 6. EDITORIAL INDEPENDENCE
22. Funding body23. Competing interests
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CPG Implementation“The concrete activities and interventions undertaken to turn policies into desired results“
Guidelines for clinical practice: from development to use. IOM, 1992
CPGs Practice
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Implementation researchis the scientific study of methods to promote the systematic uptake of proven clinical treatments, practices, organizational, and management interventions into routine practice, and hence to improve health.In this context, it includes the study of influences on patient, healthcare professional, and organizational behavior in either healthcare or population settings.http://www.nlm.nih.gov/hsrinfo/implementation_science.html
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Implementation scienceIt is the study of methods to promote the integration of research findings and evidence into healthcare policy and practice.It seeks to understand the behavior of healthcare professionals and other stakeholders as a key variable in the sustainable uptake, adoption, and implementation of evidence-based interventions.As a newly emerging field, the definition of implementation science and the type of research it encompasses may vary according [to] setting and sponsor. However, the intent of implementation science and related research is to investigate and address major bottlenecks (e.g. social, behavioral, economic, management) that impede effective implementation, test new approaches to improve health programming, as well as determine a causal relationship between the intervention and its impact.http://www.nlm.nih.gov/hsrinfo/implementation_science.html
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Dissemination
Is the purposive distribution of information and intervention materials to a specific public health or clinical practice audience.The intent is to spread information and the associated evidence-based interventions. Research on dissemination addresses how information about health promotion and care interventions is created, packaged, transmitted, and interpreted among a variety of important stakeholder groups.http://www.nlm.nih.gov/hsrinfo/implementation_science.html
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CPG ImplementabilitySet of characteristics that PREDICT the relative ease of implementation of CPG recommendations.Implementability is an abstract concept related to several factors, including intrinsic factors that are specific to the CPG itself and under control of the CPG development group and extrinsic factors that are often specific to the intended healthcare settings and context of implementation.
Implementability…….BEFORE implementation
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CPG implementation Strategies (SIGN)
Dissemination Process (print/ e-/website). Local Clinical Champions. Awareness raising/ training activities. Regular M & E (Auditing) (The ‘living’ CPG concept!). Networking and linking with existing projects (e.g. Dept.
Clinical Rounds, CPD/CME activities, Accreditation, etc..). Patients as champions for change.
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CPG implementation Toolsavailable at the point of care (* MR)
Examples1.Clinical Algorithm2. Integrated Care/ Clinical Pathways3.Protocol and/ or Policy & Procedure4.Chart Documentation/ forms (e.g. Physician Order Sets: eSIHI
CPOE PowerPlans)5.Quick Reference Guides/ Physician Guides & Pocket
Guide/Reference Cards (at-a-glance summary of key recommendations 5 or 1-2 pages).
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1.Clinical audit criteria (tool)2.Quality (outcome/performance) measures3.Slide Presentation.4.Wall Poster.5.Patient Resources/ Information (health education guides).6.Foreign language Translation (Non-English, Non-Arabic).7.Implementation Tool Kits (collections of tools and/or
strategies).8.Staff Training/ Competency Material.
CPG implementation tools (cont’d)
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Mobile Apps
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CPG Implementation Failure….WHY?
Extrinsic to CPG:provider & care system-related
Intrinsic to CPG:ambiguity – inconsistency - incompleteness
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Barriers (Physician adherence to CPGs)*
I – KNOWLEDGE:-• Lack of familiarity and/or AwarenessII – ATTITUDES:-• Lack of agreement with specific CPGs• Lack of agreement with CPGs in general• Lack of outcome expectancy• Lack of self-efficacy• Lack of motivation/ inertia of previous practice
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Barriers (cont’d)
III – BEHAVIOR:-• External factors (e.g. patient factors, care
system factors)• Internal factors (CPG factors)• Environmental factors
*Enhancing the Use of Clinical Guidelines: A Social Norms PerspectiveThe McDonnell Norms Group 2006
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Individual Positive attitude Learning through small
group interaction
Environmental• Professional
association/society support• Inter-organizational
collaboration networks
Facilitators Organizational• Leadership support• Champions• Team work
collaboration
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KSUMC CPG PROGRAMcurrent status 2015 - 1436
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Clinical Practice Guidelines (CPGs) Program of King Saud University Medical City
KSUMC CPG Program Partners:-KSUMC-Wide CPGs Steering Committee;Clinical Departments (20 CPGs Depart. Committees);
Research Chair for Evidence-Based Health Care and Knowledge Translation;
Quality Management Department; DQTsTop Management & Leadership of KSU College of Medicine and KSU Medical City
IMPLEMENTQIP
ADAPTMethods
Guidelines International Network (G-I-N)www.g-i-n.net
EBHC-KT Chair, King Saud University: Org. Member since 2009
(1st Member from Gulf & 3rd Member from MENA Countries)
Founded in Nov. 2002
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23 KSUMC CPGs Subcommittees1. Department of Pediatrics (7)2. Department of Critical Care (3. Department of Psychiatry 4. Primary Care/ Family Medicine Clinics 5. Department of Pharmacy 6. Department of Emergency Medicine 7. Department of Medicine8. Department of Orthopedic Surgery 9. Department of Otorhinolaryngology 10. Department of Ophthalmology 11. Department of Cardiac Sciences/ KFCC 12. Department of Surgery 13. Department of Obstetrics & Gynecology 14. Department of Dermatology 15. Department of Anesthesiology 16. Department of Laboratory Medicine &
Pathology
17. Department of Nursing18. Department of Radiology 19. Health Education Center 20. Department of Rehabilitation Medicine21. Department of Infection Control22. Department of Occupational Health & Safety23. Department of Clinical Nutrition
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Health/ Clinical/ Key QuestionsPatient (& disease characteristics)
Intervention(s)
Professionals (Target users)
Outcomes (purpose of the CPGs)
Healthcare settings (& context)
CPG Scope: PIPOH Model
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LevelEvidence
(LoE)
GradeRecomm
.(GoR)
Strength
EVIDENCE PYRAMID
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CPG-ICU-002 (VTE) 2013
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HWCPG-ENT-001 (ABRS) 2013
How to access the KSUMC CPGs?
• PAPER1. CPG Binder (full document)2. Forms (Implementation tools)3. Algorithm Booklet
• ELECTRONICOnline:1. QMD website (KSU email)
2. Icity website (KSU email)
3. G-I-N website (EBHCKT)
Offline: (intranet)Desktop Icon
PARADIGMSHIFT: eSiHi05/02/2023 88
CPG Binder in the Wards
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FORMS(algorithms, pathways, physician orders)
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The Clinical Algorithm Booklet
Coloured clinical algorithms of
four Pedia. CPGs-:.1Acute asthma.2DKA.3N. Jaundice.4FUS
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Desktop Icon
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Desktop Icon
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How to access CPGs on Intranet City (ICity)
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QMD Websitehttp://medicinequality.ksu.edu.sa/
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Ped. DKA
18 CPOE /28
CPGs
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Acute asthma
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EMR & CPGs• EMRs (or EHRs) & CPGs are being
incorporated into routine medical practice• Synergism exist between EHRs & CPGs
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Paper Days!If it’s not documented, you didn’t do it!
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EMR Days!“eSiHi” days
You documented it . . . . . . . . . Did you do it?
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KSUMC CPG PROGRAM IN NUMBERS KSUMC-Wide CPG Steering Committee Members: 12 Departments participating in CPG Program: 20 Health topics identified for CPGs’ projects: 53 CPG adaptation projects finalized: 33 CPGs finalized & approved by CPG Steering Committee:
28 CPGs finalized & implemented: 10 CPGs uploaded to ICity, QMD websites & desktops at points of care:
28 CPGs implemented & audited (data collected): 8 CPGs implemented & audited (data analyzed): 5
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Who is the contact person for EBCPGs in each clinical department?
Chairperson, CPG Departmental CommitteeMembers, CPG Departmental CommitteeDepartment Quality Team (former Accreditation teams)Department Chairman & Units’ HeadsGeneral Coordinator, CPG Steering CommitteeMedical Secretary, CPG Steering Committee
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Pediatrics (7)
Pediatrics (PED)
Pulmonology 1. Management of Acute Asthma exacerbations (DEM) (2nd Edition)2. Management of Acute viral Bronchiolitis (DEM) (2nd Edition)
Endocrinology 3. Management of Diabetic Ketoacidosis in children (DEM) (2nd Edition)
Infectious Diseases 4. Management of Fever without a source in infants 60 days or less (DEM) (1st Edition)
Neonatology 5. Management of Neonatal Hyperbilirubunemia (Jaundice) (1st Edition)
PICU 6. Management of Severe Sepsis and Septic Shock in infants and children (DEM) (1st Edition)
Neurology 7. Management of Status Epilepticus in infants and children (1st Edition)
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Critical Care (ICU) (2)
Critical Care (ICU) MICU
1. Management of Severe Sepsis and Septic Shock (Adult) (DEM) (1st Edition)
2. Venous Thromboembolism Prophylaxis (1st Edition)
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Medicine (6)
Medicine (MED)
Pulmonology 1. Management of Asthma in Adults (DEM) (1st Edition)
Endocrinology 2. Management of Diabetic Ketoacidosis in Adults more than 12 years of age (DEM) (1st Edition)
Rheumatology 3. Management of Gout (acute/chronic) (DEM) (1st Edition)
Clinical Teaching Unit
4. Management of Hypertensive Emergencies/Urgencies (DEM) (1st Edition)
Hematology-Oncology
5. Management of Lung Cancer (1st Edition)6. Antiemetics for Chemotherapy induced Nausea & Vomiting (1st Edition)
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Family Medicine(1)
Family Medicine (FM/PCC)
(General)Management of Dyslipidemia and prevention of atherosclerosis (1st Edition)
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Cardiac Sciences & KFCC (2)
Cardiac Sciences (KFCC)
KFCC
1. Management of Heart Failure (1st Edition)
1. Cardiac Artery Bypass Graft Surgery (1st Edition)
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Psychiatry (1)
Psychiatry (PSYCH)
(General) Management of Bipolar Disorder (1st Edition)
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Orthopedics (1)
Orthopedic Surgery
(ORTHO)
Spine surgery
Management of Persistent Non-specific Low Back Pain (PCC, DEM) (1st Edition)
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Obstetrics & Gynecology (2)
Obstetrics &
Gynecology (OBGYN)
Maternal-Fetal Medicine
1. Antenatal corticosteroids for fetal maturation (PCC) (1st Edition)
IVF & Reproductive Techno.
2. Number of Embryos to transfer in IVF Treatment (1st Edition)
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Otorhinolaryngology (ENT) (1)
ENT (General)Management of Acute Bacterial Rhino-sinusitis (PCC) (1st Edition)
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Surgery (1)
Surgery (SURG)
(General) Antimicrobial prophylaxis in surgery (1st Edition)
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Pharmacy Services (2)
Pharmacy (PHARM) Clinical
Pharmacy/ Drug Information Center
1. Vancomycin Adult Dosing and Monitoring (1st Edition)
2. Pediatric & Neonatal Total Parenteral Nutrition (1st Edition)
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Nursing (2)
Nursing (NSG) (General)
1.Surgical Site Infection Prevention (1st Edition)
2. Central Vascular Access Device (CVAD) (1st Edition)
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How to read the KSUMC CPGs full documents?Table of contents
• Preface by authors• Acknowledgments• Abbreviations• Overview material• Introduction • Statement of intent
• Scope & Purpose (PIPOH)• Recommendations (Key & details)• External review & consensus• Plan for scheduled review & update• List of funding sources• Adaptation process methodology• Implementation considerations & Tools• References
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Role of physicians in CPGs• CPG implementers/users: “Your continuous feedback!”
• CPG developers/adapters.• Improvement research projects.
