www.wspg.org.uk West of Scotland Pain Group www.nbpa.org.uk North British Pain Association

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

Content Development of evidence based guidelines Implementing evidence based guidelines Some food for thought /challenges for the future

Development of evidence based guidelines

Implementing evidence based guidelines

Some food for thought /challenges for the future

Why ( on earth) do we need guidelines?

Why ( on earth) do we need guidelines?

Many myths

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

Sackett et al. EBM, Churchill Livingstone, 1997

Conscientious, explicit and judicious use of current best evidence in making decisions about care of individual patients

Problem The evidence explosion No individual care provider can be up to date anymore

The evidence explosion

No individual care provider can be up to date anymore

Need for systematic reviews Systematic Transparent Reproducible state-of-the-art summaries

Systematic

Transparent

Reproducible state-of-the-art summaries

Clinical guidelines Systematically developed statements to assist practitioner and patient decisions about appropriate health care Recommendations No protocols, no ‘law’

Systematically developed statements to assist practitioner and patient decisions about appropriate health care

Recommendations

No protocols, no ‘law’

Development and Implementation Cycle of Guidelines

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

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

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

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

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

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)

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)

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)

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

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

One feature in common All are ‘evidence based’

All are ‘evidence based’

An intermezzo

An intermezzo

Jacob (1785-1863) & Wilhelm (1786-1859) Grimm

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’

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’

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.

Bart Koes, Maurits van Tulder, Raymond Ostelo, Kim Burton, Gordon Waddell

Spine 2001; 26: 2504-13.

Sources for differences in recommendations health care systems (organisation / financial) target population (e.g., GPs, physiotherapists)

health care systems (organisation / financial)

target population (e.g., GPs, physiotherapists)

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

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

Evidence based guidelines Or Evidence biased guided lies

Evidence based guidelines

Or

Evidence biased guided lies

Implementation of guidelines

Implementation

of guidelines

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

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

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

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

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)

Effective

Educational outreach visits

Multi professional collaboration

Financial interventions

Combined interventions

Mostly effective

Interactive small group meetings

Mass media campaigns

Reminders

Computerized decision support

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

2 hour Workshop

Discussing relevant issues

Role playing with actor

Providing pamphlets

Reminder with guidelines of Occup Phys and 2 articles

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

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

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

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

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

Inclusion of patients New referral for non-specific low back pain Exclusion: Specific low back pain Pregnancy Unable to complete questionnaires No informed consent

New referral for non-specific low back pain

Exclusion:

Specific low back pain

Pregnancy

Unable to complete questionnaires

No informed consent

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

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

Results process outcomes: % agreement with guidelines 1: ≤ 3 sessions 4: adequate information 2: adequate goals 5: all recommendations 3: active interventions

Results patient-centered outcomes Functional status (QBPDS) Pain intensity (NRS) Work absenteeism, coping, beliefs similar results l l l l l l l

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

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

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

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

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?

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?

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

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

Key messages Development : Adhere to guidelines for development Dissemination should be planned, targeted and evaluated & needs to be supplemented by active implementation strategies

Raymond Ostelo EMGO Institute, VU University Medical Centre Institute for Health Sciences, VU University r. ostelo @ vumc . nl

Raymond Ostelo

EMGO Institute, VU University Medical Centre

Institute for Health Sciences, VU University

r. ostelo @ vumc . nl