CARI update Governed by: Kidney Health Australia


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CARI update Governed by: Kidney Health Australia

  1. 1. CARI update Governed by: Kidney Health Australia Australian & New Zealand Society of Nephrology Sponsored by: Amgen Australia Janssen Cilag Pty Ltd Genzyme Australasia Pty Ltd Roche Pharmaceuticals Grants received: NHMRC Centre of Clinical Research Excellence, 2002-2007 Dept of Health & Ageing
  2. 2. Overview <ul><li>What is CARI? </li></ul><ul><ul><li>Guideline work and its application </li></ul></ul><ul><ul><li>Other effects </li></ul></ul><ul><li>Challenges: </li></ul><ul><ul><li>KDIGO </li></ul></ul><ul><ul><li>Funding </li></ul></ul><ul><ul><li>Review </li></ul></ul>
  3. 3. What is CARI? Background <ul><li>Dialysis & Transplantation Committee proposed in Dec 1998 that local clinical practice guidelines were needed </li></ul><ul><li>KDOQI had just emerged </li></ul><ul><ul><li>Concerns about applicability beyond US </li></ul></ul><ul><ul><li>Concerns about being “opinion based” </li></ul></ul><ul><li>Dec 1998 Steering Committee set up and CARI commenced in 1999 </li></ul>
  4. 4. What is CARI? Australian and New Zealand Society of Nephrology AND Kidney Health Australia (DNT Subcommittee) Steering Committee (13 members) Guideline Groups (comprise Convenors and Members 17 guideline groups) CARI Guidelines Editorial Office (2.0FTE staff)
  5. 5. Extensive body of work <ul><li>CKD: </li></ul><ul><ul><li>Prevention of progression of CKD </li></ul></ul><ul><ul><li>Nutrition and Growth </li></ul></ul><ul><ul><li>CV risk </li></ul></ul><ul><ul><li>VitD, Calcimimetics & PO4 </li></ul></ul><ul><ul><li>Urine protein </li></ul></ul><ul><ul><li>Kidney stones </li></ul></ul><ul><ul><li>Renal vasculitis </li></ul></ul><ul><li>Dialysis guidelines </li></ul><ul><ul><li>Acceptance onto Dialysis </li></ul></ul><ul><ul><li>Biochem and Haem targets </li></ul></ul><ul><ul><li>Dialysis adequacy </li></ul></ul><ul><ul><li>Evidence for PD peritonitis </li></ul></ul><ul><ul><li>Vascular Access </li></ul></ul><ul><li>Transplantation: </li></ul><ul><ul><li>Decreased donor suitability </li></ul></ul><ul><ul><li>CMV and kidney transplantation </li></ul></ul><ul><ul><li>Calcineurin inhibitors </li></ul></ul><ul><ul><li>Living Kidney donors </li></ul></ul>
  6. 6. Place of that work <ul><li>Publication in Nephrology: </li></ul><ul><ul><li>4 of the top 10 are CARI publications </li></ul></ul><ul><ul><li>Most popular: Kidney stones guidelines </li></ul></ul><ul><li>Hits on websites </li></ul><ul><li>Approach from National Guidelines Clearing House </li></ul><ul><li>Survey results (2006)* </li></ul><ul><ul><li>Changed practice: 40% 60% </li></ul></ul><ul><ul><li>Improved pt outcomes: 14% 40% </li></ul></ul><ul><ul><li>Not matching evidence: 29% 8% </li></ul></ul><ul><li>Qualitative research </li></ul>* Irving M, et al AJKD
  7. 9. Guidelines in clinical decision making <ul><li>Qualitative project </li></ul><ul><ul><li>Michelle Irving </li></ul></ul><ul><li>19 face to face interviews with nephrologists </li></ul><ul><ul><li>4 Victoria – 2 rural </li></ul></ul><ul><ul><li>7 Queensland – 2 rural </li></ul></ul><ul><ul><li>8 NSW – 2 rural </li></ul></ul><ul><li>Guidelines: </li></ul><ul><ul><li>often confirms practice rather than changes it. </li></ul></ul><ul><ul><li>Are a back bone to practice, create a sense of certainty </li></ul></ul><ul><ul><li>Are a good summary of evidence </li></ul></ul><ul><ul><li>Are a component of decision making </li></ul></ul><ul><ul><li>Patients quality of life will take precedence over a guideline </li></ul></ul>
  8. 10. Quotable quotes <ul><li>“ They are a fantastic summary; there is no question about that.’ </li></ul><ul><li>“… a lot of the time they don’t change your practice because in fact, you’re already doing it right, so it confirms practice rather than changing it.” </li></ul><ul><li>“ You know in the real world it’s impossible to meet those targets in all of your patients, all of the times.” </li></ul><ul><li>“… , you can’t make their life intolerable, to meet a standard.” </li></ul><ul><li>“… I trust my peers that have reviewed the guideline.” </li></ul><ul><li>“… you know why don’t we just adopt KDIGO? The benefit of the local ones is that they tend to be a bit more sceptical of it, and less prescriptive of things that aren’t proven, or has a benefit.” </li></ul><ul><li>“ I’ve been doing it for a long time, I kind of feel I know it all, in the back of my head.” </li></ul><ul><li>“ Usually if there is clear evidence then we change our practice.” </li></ul>
  9. 11. Other CARI effects <ul><li>Engagement of the workforce: </li></ul><ul><ul><li>22 convenors, approx 100 members of groups </li></ul></ul><ul><li>Epidemiological literacy </li></ul><ul><ul><li>Unique in ANZ </li></ul></ul><ul><li>Highlights what we don’t know </li></ul><ul><li>Impt driver of AKTN </li></ul><ul><li>Implementation projects </li></ul>
  10. 12. Implementation projects <ul><li>Unique among guidelines bodies </li></ul><ul><li>Response to glaring failure to implement evidence </li></ul><ul><li>Anaemia: </li></ul><ul><ul><li>Audits and implementation of 6 Units </li></ul></ul><ul><li>Vascular Access: </li></ul><ul><ul><li>Baseline data from 8 Units </li></ul></ul><ul><ul><ul><li>Kevan later today </li></ul></ul></ul><ul><ul><li>Grant application proceeding </li></ul></ul><ul><li>Issues: </li></ul><ul><ul><li>Resourcing </li></ul></ul><ul><ul><li>Ability of external bodies to influence within a unit </li></ul></ul><ul><ul><li>Impt lessons and expertise gained </li></ul></ul>
  11. 13. Things we need to improve <ul><li>Widen the consuming audience: </li></ul><ul><ul><li>Most relevant to nephrologists </li></ul></ul><ul><ul><ul><li>Partly a function of a volunteer workforce </li></ul></ul></ul><ul><ul><li>GP, patients, allied health </li></ul></ul><ul><li>Greater engagement with consumers </li></ul><ul><ul><li>Develop a network of consumers </li></ul></ul><ul><ul><li>Panels to review each guideline </li></ul></ul><ul><li>Dissemination </li></ul><ul><ul><li>More regular communication with ANZSN m’ship </li></ul></ul><ul><li>Updating of guidelines </li></ul><ul><li>Adjust to changing circumstances </li></ul>
  12. 14. Challenges: KDIGO <ul><li>Kidney Disease: Improving Global Outcomes </li></ul><ul><li>Mission to: </li></ul><ul><ul><li>“ To improve the care and outcomes of kidney disease patients worldwide through promoting coordination, collaboration and integration of initiatives to develop and implement clinical practice guidelines.” </li></ul></ul><ul><li>Not for profit, incorporated in Belgium </li></ul><ul><li>Governed by an international board: </li></ul><ul><ul><li>~50 members </li></ul></ul><ul><ul><li>3 year terms, then Board of Counsellors </li></ul></ul><ul><li>Managed by NKF </li></ul><ul><li>No formal local guideline representation </li></ul>
  13. 15. KDIGO: output <ul><li>Hepatitis C : </li></ul><ul><ul><li>April 2008 </li></ul></ul><ul><ul><li>Page 89 of 107: </li></ul></ul><ul><ul><ul><li>On the basis of the list of topics, the Work Group and Evidence Review Team developed (i) draft guideline statements; (ii) draft rationale statements that summarized the expected pertinent evidence; </li></ul></ul></ul><ul><ul><li>Page 90 of 107: </li></ul></ul><ul><ul><ul><li>The Work Group members had latitude to review and cite other articles that did not meet the systematic review eligibility criteria,…including opinion pieces </li></ul></ul></ul><ul><li>CKD Mineral and Bone Disorders : </li></ul><ul><ul><li>Publish 2009 </li></ul></ul><ul><li>Care of the Kidney Transplant Recipient: </li></ul><ul><ul><li>Publish 2009 </li></ul></ul><ul><li>Acute Kidney Injury: </li></ul><ul><ul><li>Publish 2010 </li></ul></ul><ul><li>Glomerulonephritis: </li></ul><ul><ul><li>Publish 2010 </li></ul></ul><ul><li>Diabetes, Anaemia, Hypertension… </li></ul>
  14. 16. What does KDIGO mean locally? <ul><li>Just use KDIGO? </li></ul><ul><ul><li>Limited local expertise and engagement </li></ul></ul><ul><ul><li>Still some issues with the product </li></ul></ul><ul><ul><li>Can we outsource guidelines to an organisation: </li></ul></ul><ul><ul><ul><li>incorporated in Belgium </li></ul></ul></ul><ul><ul><ul><li>with no formal relationships to any local organisation </li></ul></ul></ul><ul><ul><ul><li>With questionable administrative structures </li></ul></ul></ul><ul><ul><li>Government view? </li></ul></ul><ul><li>Response to Hep C: </li></ul><ul><ul><li>Nephrology editorial </li></ul></ul><ul><li>Decision to adapt guidelines </li></ul><ul><ul><li>ADAPTE tool </li></ul></ul><ul><ul><li>Significant investment </li></ul></ul><ul><ul><li>Limited experience locally </li></ul></ul><ul><ul><ul><li>NHMRC using for VTE </li></ul></ul></ul><ul><li>Reduction in new guideline development </li></ul><ul><li>Greater role for implementation </li></ul>
  15. 17. Funding <ul><li>Annual round of pharmaceutical companies </li></ul><ul><ul><li>Dedicated implementation funding </li></ul></ul><ul><li>Individual contract with Diabetes Australia for Diabetes Guideline: </li></ul><ul><ul><li>Presented yesterday </li></ul></ul><ul><li>Access to some CCRE resources for searches and literature review </li></ul><ul><li>Other sources: </li></ul><ul><ul><li>Beneficiaries of our work: Government </li></ul></ul><ul><ul><li>Many state govts make reference to CARI as “industry standards” </li></ul></ul>
  16. 18. CARI Review <ul><li>Suggested by ANZSN and DNT </li></ul><ul><li>Funding set aside </li></ul><ul><li>Timeline March-June 2009 </li></ul><ul><li>Terms of reference: </li></ul><ul><ul><li>Establish the standing of the body of work of the CARI Guidelines within the world literature of renal guidelines. </li></ul></ul><ul><ul><li>Comment upon the relative value for money of this body of work (including the contribution of the volunteer workforce of guideline developers) in an international renal guidelines context. </li></ul></ul><ul><ul><li>Comment upon the feasibility of the existing CARI Guidelines work being performed by other bodies (either local or international) to a similar to higher standard using historical funding levels. </li></ul></ul><ul><ul><li>Suggest future areas for investment by CARI Guidelines to ensure ongoing relevance. Within this item, the Review Panel should comment specifically upon the balance of investment between new guideline development, updating of existing guidelines, guideline implementation projects and adaptation of international guidelines performed by CARI. </li></ul></ul><ul><ul><li>In light of above recommendations, to comment upon appropriate funding levels and strategies by which secure and long term funding might be derived. </li></ul></ul>
  17. 19. Summary <ul><li>CARI: </li></ul><ul><ul><li>Diverse, well respected and used guidelines </li></ul></ul><ul><ul><li>Lots more than just guidelines </li></ul></ul><ul><ul><ul><li>Fundamental component of ANZ nephrology </li></ul></ul></ul><ul><li>Challenges for the future </li></ul><ul><ul><li>Making int. guidelines locally relevant </li></ul></ul><ul><ul><li>Resourcing </li></ul></ul><ul><ul><li>Changing to reflect the environment </li></ul></ul>