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Guidelines - what difference do they make? A Dutch perspective

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This lecture was given by Dr Raymond Ostelo of the EMGO Institute, VU University Medical Center, Amsterdam, to the North British Pain Association Spring Scientific Meeting in Edinburgh on Friday 18th …

This lecture was given by Dr Raymond Ostelo of the EMGO Institute, VU University Medical Center, Amsterdam, to the North British Pain Association Spring Scientific Meeting in Edinburgh on Friday 18th May, 2007. His lecture forms part of a conference "Blurring the Boundaries - Managing Pain in Primary Care and Secondary Care".

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  • 1. www.wspg.org.uk West of Scotland Pain Group www.nbpa.org.uk North British Pain Association
  • 2. Guidelines What difference do they make? a Dutch perspective Raymond Ostelo, PhD, PT EMGO Institute, VU University Medical Centre Institute for Health Sciences, VU University Acknowledgement: Maurits van Tulder, Arno Engers
  • 3. Content
    • Development of evidence based guidelines
    • Implementing evidence based guidelines
    • Some food for thought /challenges for the future
  • 4.
    • Why ( on earth) do we need guidelines?
  • 5. Many myths
  • 6. Evidence based practice
    • Sackett et al. EBM, Churchill Livingstone, 1997
    • Conscientious, explicit and judicious use of current best evidence in making decisions about care of individual patients
  • 7. Problem
    • The evidence explosion
    • No individual care provider can be up to date anymore
  • 8.  
  • 9. Need for systematic reviews
    • Systematic
    • Transparent
    • Reproducible state-of-the-art summaries
  • 10. Clinical guidelines
    • Systematically developed statements to assist practitioner and patient decisions about appropriate health care
    • Recommendations
    • No protocols, no ‘law’
  • 11. Development and Implementation Cycle of Guidelines
  • 12. Implementing Evidence Building Evidence Systematical Literature studies Clinical guidelines study the optimal implementation strategies Audit / monitoring Study the effect of implementation define health care problem Experimental studies Observational studies Economical evaluation
  • 13. Implementing Evidence Building Evidence Systematical Literature studies Clinical guidelines study the optimal implementation strategies Audit / monitoring Study the effect of implementation Low Back Problem Experimental studies Observational studies Economical evaluation
  • 14. Implementing Evidence Building Evidence Systematical Literature studies Clinical guidelines study the optimal implementation strategies Audit / monitoring Study the effect of implementation Low Back Problem RCTs on effectiveness & Cost effectiveness
  • 15. Implementing Evidence Building Evidence Sufficient number of systematic (or structured) reviews Clinical guidelines study the optimal implementation strategies Audit / monitoring Study the effect of implementation Low Back Problem RCTs on effectiveness & Cost effectiveness
  • 16. Implementing Evidence Sufficient number of systematic (or structured) reviews
    • Clinical guidelines in the Netherlands:
    • - GP (NHG) guidelines (updated 2004)
    • - Physiotherapy (KNGF) (2001)
    • - Occupational Physicians (NVAB) (1999)
    • - Manual Therapy (NVMT) (2003)
    • DI Healthcare Imp. ( CBO) (2003)
    • Dutch Health Council (2007)
    study the optimal implementation strategies Audit / monitoring Study the effect of implementation Low Back Problem RCTs on effectiveness & Cost effectiveness
  • 17. Some features of Dutch guidelines
    • Mono disciplinary
      • GP (NHG) guidelines (updated 2004)
      • Physiotherapy (KNGF) (2001)
      • Occupational Physicians (NVAB) (1999)
      • Manual Therapy (NVMT) (2003)
    • Multidisciplinary
      • Dutch Institute Healthcare Improvement ( CBO) (2003)
      • Dutch Health Council (2007)
  • 18. Some features of Dutch guidelines
    • Different methodologies for development
      • Advisory committee and writing panel
      • Subcommittees who are responsible for different parts
    • Different methodologies for grading the evidence
      • Strict criteria (e.g. at least 1 good quality systematic review: ‘level 1’, use phrase ‘it has been shown’ for recommendation
      • quality criteria and formulations more loosely used
  • 19. One feature in common
    • All are ‘evidence based’
  • 20.
    • An intermezzo
  • 21. Jacob (1785-1863) & Wilhelm (1786-1859) Grimm
  • 22. An evidence based f airy tale
    • Once there was … a guideline committee and they defined the health care problem & searched for the evidence
    • then summarized the evidence…
    • Then the orthopedists, anesthesiologists & the neurosurgeons did not like the evidence that was not in favor of surgery
    • They redefined the health care problem so that they could omit the unfavorable evidence
    • They sponsored the guideline so the guideline committee (grudgingly) ‘agreed’
  • 23. Clinical guidelines for the management of low back pain in primary care: an international comparison
    • Bart Koes, Maurits van Tulder, Raymond Ostelo, Kim Burton, Gordon Waddell
    • Spine 2001; 26: 2504-13.
  • 24. Sources for differences in recommendations
    • health care systems (organisation / financial)
    • target population (e.g., GPs, physiotherapists)
  • 25. Sources for differences in recommendations
    • health care systems (organisation / financial)
    • target population (e.g., GPs, physiotherapists)
    • magnitude of effects
    • (in)completeness of evidence
    • methods of grading the evidence
    • membership of guidelines committees
    Clinical Judgment
  • 26.
    • Evidence based guidelines
    • Or
    • Evidence biased guided lies
  • 27.
    • Implementation
    • of guidelines
  • 28.  
  • 29. Background
    • Room for improvement in adhering to the GP guideline
    • Referral to physiotherapy for acute LBP pain
    • Time contingent approach
      • medication
      • bed rest
    • Medication
      • First choice: paracetamol
      • Second choice: NSAID’s
  • 30. A multifaceted implementation strategy: aims
    • Enhance patient education skills
    • Improve referral practices for MT and PT
    • Increase the use of written information (pamphlets)
    • Increased knowledge of the guideline & relevant scientific evidence
  • 31. Why a multifaceted implementation strategy?
    • Effective
      • Educational outreach visits
      • Multi professional collaboration
      • Financial interventions
      • Combined interventions
    • Mostly effective
      • Interactive small group meetings
      • Mass media campaigns
      • Reminders
      • Computerized decision support
    (Grol & Grimshaw. Lancet 2003; 362: 1225-30)
  • 32.
    • 2 hour Workshop
      • Discussing relevant issues
      • Role playing with actor
    • Providing pamphlets
    • Reminder with guidelines of Occup Phys and 2 articles
    A multifaceted implementation strategy: training
  • 33.  
  • 34.  
  • 35.  
  • 36. Results
    • A multifaceted intervention slightly modified the management behaviour of GPs in terms of fewer referrals to therapists during follow-up consultations
    • It did not lead to more adequate provision of information to patients
  • 37. Discussion
    • GPs in control group also performed well
      • Is further improvement called for?
    • Perhaps focus on situations where adherence to the clinical guidelines is known to be limited
  • 38.  
  • 39. Physiotherapists 113 PTs randomised 61 Standard Dissemination 2 drop outs 11 no data 4 drop outs 11 no data   - - 52 Active Implementation N=37 N=48 Same as Engers
  • 40. Inclusion of patients
    • New referral for non-specific low back pain
    • Exclusion:
      • Specific low back pain
      • Pregnancy
      • Unable to complete questionnaires
      • No informed consent
  • 41. Process-oriented outcome measures
    • Blinded evaluation of registration forms by 2 researchers using algorithm for 4 key recommendations:
      • Limited number of sessions normal course
      • Goals focussing on activity and participation
      • Using active interventions
      • Giving adequate advise and information
  • 42. Results process outcomes: % agreement with guidelines 1: ≤ 3 sessions 4: adequate information 2: adequate goals 5: all recommendations 3: active interventions
  • 43. Results patient-centered outcomes Functional status (QBPDS) Pain intensity (NRS) Work absenteeism, coping, beliefs similar results l l l l l l l
  • 44. Conclusion
    • The implementation strategy
      • slightly improved adherence to the guideline
      • did not result in additional beneficial effects on patient outcomes
    • Possible explanation: contrast in adherence between the two groups too small
  • 45. Discussion
    • Active strategies for implementing seem (not only from these studies) not beneficial on patient outcomes
    • Still there might be other good reasons for using an active strategy to implement guidelines
    • In case of similar outcomes, a more transparent health care process or reduction in costs can be reasons to recommend this strategy broadly
  • 46. F ood for thought
    • Development
      • Think before you leap: www.agreecollaboration.org
      • Clinical guidelines are based on systematic reviews (and/or individual studies) plus clinical expertise
      • Saying an guideline is evidence based doesn’t make it evidence based by itself
      • Do weed need mono- or multidisciplinary guidelines?
  • 47. More f ood for thought
    • Should we adapt existing guidelines or develop them all over again?
    • Implementation of guidelines challenge for the near future especially for practitioners not participating in trials
  • 48. Key messages Development : Adhere to guidelines for development Dissemination should be planned, targeted and evaluated & needs to be supplemented by active implementation strategies
  • 49.
    • Raymond Ostelo
    • EMGO Institute, VU University Medical Centre
    • Institute for Health Sciences, VU University
    • r. ostelo @ vumc . nl

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