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Evidence-Based Clinical Practice Guidelines
(EBCPGs)For Medical Staff of
Healthcare Organizations (HCOs)
2013
IntroductionBy
Dr. Yasser Sami A. Amer, MBBCh, MSPediatrician - HC Informatician
EBCPGs Advisor & Trainer
Concepts & Definitions
Two Different Approaches to Evidence-Based Practice (EBP)
Clinical Practice Guidelines (CPGs)•“Top-down” approach• Tell clinicians how to practice• Favored by health care systems
Evidence-Based Medicine (EBM)•“Bottom-up” approach• Teach clinicians how to find answers• Favored by medical educators
EBM definitionThe integration of best research evidence
with clinical expertise and patient valuesSackett et al 2000
Clinical Expertise
Research
Evidence
PatientPreference
s
What is “EBM” NOT?• What we have always done !;
(not old hat or just the same old medical practice; as evidenced in wide practice variation)
• “Cookbook Medicine”!EBM specifically advocates for individualized application of evidence to patient care, not forcing patient care to conform to generalized evidence
• Only a cost-cutting trick !;it is intended to guide practitioners to provide the best, not necessarily the cheapest, care.
• Only RCTs !;(Also with best relevant evidence applicable to the situation in question)
– EBM is tracking down the best external evidence from scientific research to answer our clinical question(s)…
Definition: (old)“Systematically developed statements to assist
practitioner and patient decisions about appropriate health care for specific clinical circumstances” (Institute of Medicine 1990).
Increasing international interest in the development and implementation of CPGs.
Clinical Practice Guidelines (CPGs)
CPGs New DefinitionCPGs are “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)
Why do we need guidelines?
Rationale for CPGs•Worldwide concerns about: ▫Unexplained variations in clinical practice▫Rising health care costs▫Exponential growth of information
• Aim of Clinical Practice Guidelines:▫To facilitate more consistent, effective and
efficient practice and improve health outcomes for patients
Evidence-Based CPGs
Clinical Care GAP
Current Practice
Best PracticeGuidelines
Who needs guidelines?
Stakeholders
•Doctors•Nurses•Decision makers•Patients•Public
Guidelines on the Web
Guidelines on the Web
Guideline Producers
Guideline Finders
CPG Producers:Specialized Societies: e.g. AAP
SIGNScottish
Intercollegiate Guidelines Network
www.sign.ac.uk
CPG Producers:National Agencies
CPG Producers:National Agencies
NICENational Institute for
Health & Clinical Excellence
www.nice.org.uk
CPG Finders
PubMedUS National Library of
MedicineNational Institutes of
Health (NIH)
Some CPGs are only retrievable by “Googling” them!
How do we react to guidelines?
Read
AdoptAdapt
Develop
CPGs ?
Topic
Team
Content
Search
FOUND NOT FOUND
Appraise Develop
AppraiseAdopt or Adapt
Implement
Evaluate impact
Adaptation of Clinical Practice Guidelines
The ADAPTE collaboration is an international collaboration of CPG researchers, developers and implementers. Their main aim is to develop and validate a generic adaptation process that will foster valid and high-quality adapted guidelines as well as the user’s sense of ownership of the adapted guideline.Since 2009 The ADAPTE Collaboration has merged into the Guidelines
International Network (G-I-N) with all its resources to form the G-I-N Adaptation Working Group
Guideline Adaptation• Is 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.
• http://www.adapte.org/
©Copyright ADAPTE 2007
We identified 3 main ADAPTE steps:-
Adaptation Phase
Search & Selection of source CPGsHealth Questions (PIPOH)
AGREE II InstrumentAssess source CPGs quality
External Review(Departmental Consensus)
CPG Scope: PIPOH Model
Patient (& disease characteristics)
Intervention(s)
Professionals (Target users)
Outcomes (purpose of the CPGs)
Healthcare settings (& context)
= Health/ Clinical/ Key Questions
Evidence Pyramid
MA
RCT
Cohort
Case control
Case series
Case report
Expert opinion
I
II
III
IV
A
B
CLeve
ls o
f Evi
denc
eG
rades of Recom
mendations
How to assess of the quality of any CPG?
Assess guideline quality
ADAPTE TOOL 9 AGREE II Instrument
23 items in 6 domains 7 point response scale Domain scores Recommendations
AGREE II DomainsDOMAINS
1 Scope & Purpose
2 Stakeholder Involvement
3 Rigour of Development
4 Clarity & Presentation
5 Applicability
6 Editorial Independence
Hospital Official CPGs:Two separate documents
FIRST (Clinicians’ Version)• Accessible from ALL points-of-care
for the hospital staff:• Details of evidence-based
recommendations for management (with only references to the other document)
SECOND:(Methodologist’s Version) ;
• Accessible from Libraries
of e.g. Department, College of Medicine, CPG Committee, QMD, Authorship group,…etc. (Reference for Replication & Documentation)
• Detailed description of the CPG Adaptation process with ALL relevant data.
Dissemination & Implementation
Nothing could be more frustrating than producing
a CPG that is then ignored by not being
disseminated nor implemented
Dissemination of CPGs•Full CPGs documents published on
websites - integrated into HCO’s Health Information System (HIS) & Electronic Medical Records (EMRs)
•Implementation tools will also be published: examples for choice:-▫Quick Reference Guide (Summary Key Rs)▫Clinical Algorithms (decision tree)▫Clinical pathways (Integrated care pathways)▫Patient Information (Education Guide)▫Gantt chart for dissemination & Implementation▫Audit and Research Rs.
• If CPGs are to have a positive impact on patient care outcomes they must be implemented and incorporated into everyday clinical practice
• The identification of any barriers to implementation, and strategies for overcoming them, will form an essential part of discussions at CPGs Subcommittee/ Adaptation Group meetings
Implementing Guidelines
Launching ofClinical Practice Guidelines
Taskforce membersTEAM WORK
1999
2004
2006
Alexandria University HospitalsHealthcare Quality Directorate
Center for Evidence-Based Clinical Practice Guidelines(AUH – HCQD, CEBCPGs)
(Founded Nov. 2008)
Member of Guidelines International Network (G-I-N)(Since May 2009)
2005• It all started with a• VISION…….. a DREAM !
2007• Then a Thesis
2008• Then a Foundation………• A Reality ! ………..CEBCPGs
History of the Center
IS THE SECOND MEMBER OF G-I-N FROM THE MIDDLE EAST, ARAB & AFRICAN COUNTRIES;
AFTER SUDAN EVIDENCE-BASED ASSOCIATION (SEA) SINCE 2009.
(ACCORDING TO G-I-N ANNUAL REPORT 2009)
Founding Members 2008
• Prof. Dr. Mahmoud Elzalabany• Prof. Dr. Tarek Omar• Prof. Dr. Afaf Ibrahim• Prof. Dr. Nabil Dowidar• Dr. Yasser S. Amer• Dr. Hossam Ashour• Eng. Ahmed Mourady
G-I-N Annual Report 2009 EGYPT (EG)
First Workshop in Egypt: Adaptation of CPGs2009 (AFM-GIN-ADAPTE)
*12 M.Sc. Theses plus 1 Ph.D. thesis to produce 13 Adapted EBCPGs
4 Finalized Adapted CPGs by CEBCPGs, HCQD-AUHs through MSc Theses (till 3/2012) in PEDIATRICS DEPT.:1- Treatment of Acute Childhood Asthma in ER - AUCH: Dr. Yasser Sami Amer (Finalized, Approved , Disseminated & Implemented).2- Treatment of Positioning & Attachment Breast Feeding Problems in BFCC - AUCH: Dr. Georgina Ramsis (Finalized & Approved).3- Triage and Acuity Scale in A & E Dept., AMUH: Dr. Mary Christeen Nabiel Sharobeem (Finalized, Approved & Disseminated ) – the only thesis outside the Pediatrics Dept.4- Treatment of HIE in Neonates in NICU: Dr. Walid Gamal AbdelKhaliq (Finalized & Approved).5- Treatment of ADHD in children in AUCH: Dr. Mariana Iskander Amin9 Adapted CPGs in progress by Pediatrics Dept. & CEBCPGs, HCQD-AUHs through MSc/PhD Theses (till 8/2012):1. Diagnosis of acute attack of seizures in AUCH: Dr. Soheir Farouk AbdelSalam (Set
Up Phase).2. Treatment of acute attack of seizures in AUCH : Dr. Islam Yousry A.Moneium (Set Up
Phase).3. Management of Epilepsy in children in AUCH: Dr. Shimaa Anwar (Set Up Phase)4. Treatment of Childhood Autism in AUCH: Dr. Farioz Ibrahim (Set Up Phase).5. Management of Acute Bacterial Meningitis in AUCH: Dr Mariam Adly (Set Up Phase).6. Treatment of Chronic Asthma in AUCH: Dr. Reem Galal Ghazal (Set Up Phase).7. Treatment of Community Acquired Pneumonia in AUCH: Dr. Zobaida Eltazmany (Set
Up Phase).8. Treatment of Allergic Rhinitis in AUCH: Dr. Shahinaz (Set Up Phase).
Alexandria CEBCPGs Adapted ADAPTE
Methods for CPGs adaptation
5 Finalized Adapted CPGs
Official website: http://www.alexmed.edu.eg/?page_id=1278
Last accessed 8/2012
https://www.facebook.com/pages/Alexandria-Center-for-Evidence-Based-Clinical-Practice-Guidelines/124300224291530?ref=hl
Sincere Thanks & Gratitude toSenior Members of the Founding Committee (FC) of
CEBCPGs
Prof. Dr. Nabil DowidarProfessor of General Surgery , MRIHead, Alexandria Center for EBM, MRIFounding Member, Health Governance Unit, MRIFormer Dean, MRIMedical Research Institute (MRI)
Prof. Dr. Afaf IbrahimProfessor of Public Health, Social & Preventive Medicine, AFMHead, Community Medicine Dept. Director, CEBCPGs , HCQD-AUHs
Thanks & Gratitude toMembers of the Founding Committee (FC) of
CEBCPGs, HCQD-AUHs
Dr. Yasser Sami AmerM.Sc. Pediatrics, M.Sc. Healthcare InformaticsHospital Clinical Guidelines & Pathway General Coordinator, CEBCPGs, HCQD-AUHs, Primary Contact Person for G-I-N
Dr. Hossam DhorghamM.Sc. Pediatrics, M.Sc. Healthcare ManagementFormer Healthcare Quality Coordinator, HCQD-AUHsFormer Head, Accreditation & Licensure Directorate, HCQD-AUHs
Eng. Ahmed MouradyCommunication & Electronics EngineerE-Learning Consultant, Former Local Project Manager, Modernization of AUHs in Smouha
Special Thanks & Gratitude to
Prof. Dr. Tarek OmarProfessor of Pediatrics & Ped. Neurology, AFM
General Supervisor CEBCPGs & HCQD-AUHs.Former Head, AUHs Sector
Special Thanks & Gratitude tothe Founder of the HCQD-AUHs & CEBCPGs
Prof. Dr. Mahmoud El-ZalabanyProfessor of Pediatrics & Ped. Respiratory, Allergy & Immunology
Former Dean, AFMFormer Chairman, AUHs Board
G-I-N 2009 Lisbon
G-I-N 2012 Berlin
Dr. Yasser Sami Amer
MSc Pediatrics, MSc HC Informatics
EBCPGs Advisor & Trainer
