Evidence-Based Clinical Practice Guidelines for Medical Staff of Health Care Organizations


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An introduction on Evidence-Based Clinical Practice Guidelines in Health Care Organizations
Brief on Alexandria Center for EBCPGs in Alexandria University Hospitals, Egypt
By Dr. Yasser Sami Abdel Dayem Amer, MBBCh, MS 2013
Special Thanks to
Prof Dr Mahmoud Elzalabany
Prof Dr Tarek Omar
Prof Dr Nabil Dowidar
Prof Dr Afaf Gaber

Published in: Health & Medicine
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Evidence-Based Clinical Practice Guidelines for Medical Staff of Health Care Organizations

  1. 1. Evidence-Based Clinical Practice Guidelines (EBCPGs) For Medical Staff ofHealthcare Organizations (HCOs) Introduction By Dr. Yasser Sami A. Amer, MBBCh, MS Pediatrician - HC Informatician EBCPGs Advisor & Trainer 2013
  2. 2. Concepts & Definitions
  3. 3. Two Different Approaches to Evidence-Based Practice (EBP)Clinical Practice Guidelines (CPGs) •“Top-down” approach • Tell clinicians how to practice • Favored by health care systemsEvidence-Based Medicine (EBM) •“Bottom-up” approach • Teach clinicians how to find answers • Favored by medical educators
  4. 4. EBM definitionThe integration of best research evidence Clinical with clinical expertise and patient values Expertise Sackett et al 2000 Research Patient Evidence Preferences
  5. 5. 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)…
  6. 6. Clinical Practice Guidelines (CPGs)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.
  7. 7. CPGs New DefinitionCPGs are “Statements that includeRecommendations intended to optimizepatient care that are informed by aSystematic Review of evidence and anassessment of the benefits and harms ofalternative care options”. Committee on Standards for Developing Trustworthy CPGs (IOM- AHRQ)
  8. 8. Why do we need guidelines?
  9. 9. 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
  10. 10. Clinical BestCare GAP Practice
  11. 11. Who needs guidelines?
  12. 12. • Doctors• Nurses• Decision makers• Patients• Public
  13. 13. CPG Producers:Specialized Societies: e.g. AAP
  14. 14. CPG Producers: National Agencies SIGN Scottish IntercollegiateGuidelines Network www.sign.ac.uk
  15. 15. CPG Producers: National Agencies NICENational Institute for Health & Clinical Excellence www.nice.org.uk
  16. 16. AHRQNational Guideline Clearinghouse www.guidelines.gov
  17. 17. Guidelines Internationa l Network (G-I-N)www.g-i-n.net
  18. 18. PubMedUS National Library of MedicineNational Institutes of Health (NIH)
  19. 19. Some CPGs are only retrievable by “Googling” them!
  20. 20. How do we react to guidelines?
  21. 21. Develop Adapt AdoptRead CPGs ?
  22. 22. Topic Team Content Search FOUND NOT FOUND Appraise DevelopAdopt or Adapt Appraise Implement Evaluate impact
  23. 23. Adaptation of Clinical Practice Guidelines The ADAPTE collaboration is aninternational collaboration of CPG researchers, developers andimplementers. Their main aim is to develop and validate ageneric adaptation process that will foster valid and high-qualityadapted guidelines as well as the user’s sense of ownership ofthe 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
  24. 24. 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/
  25. 25. ©Copyright ADAPTE 2007
  26. 26. Adaptation PhaseWe identified 3 main ADAPTE steps:- Search & Selection of source CPGs Health Questions (PIPOH) AGREE II Instrument Assess source CPGs quality External Review (Departmental Consensus)
  27. 27. CPG Scope: PIPOH ModelPatient (& disease characteristics)Intervention(s)Professionals (Target users)Outcomes (purpose of the CPGs)Healthcare settings (& context) = Health/ Clinical/ Key Questions
  28. 28. Evidence Pyramid Grades of Recommendations MALevels of Evidence I A RCT Cohort II Case control B Case series III Case report IV Expert opinion C
  29. 29. How to assess of the quality of any CPG ?
  30. 30. Assess guideline qualityADAPTE TOOL 9 AGREE II Instrument23 items in 6 domains 7 point response scale Domain scores Recommendations
  31. 31. AGREE IIDOMAINS Domains 1 Scope & Purpose 2 Stakeholder Involvement 3 Rigour of Development 4 Clarity & Presentation 5 Applicability 6 Editorial Independence
  32. 32. Hospital Official CPGs: Two separate documentsFIRST (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)
  33. 33. 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.
  34. 34. Dissemination & Implementation Nothing could be morefrustrating than producinga CPG that is then ignoredby not being disseminated nor implemented
  35. 35. 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.
  36. 36. Implementing Guidelines• 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
  37. 37. Launching ofClinical Practice Guidelines Taskforce members TEAM WORK
  38. 38. 20061999 2004
  39. 39. Alexandria University Hospitals Healthcare Quality DirectorateCenter for Evidence-Based Clinical Practice Guidelines (AUH – HCQD, CEBCPGs) (Founded Nov. 2008) Member of Guidelines International Network (G-I-N) (Since May 2009)
  40. 40. 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
  41. 41. G-I-N Annual Report 2009 EGYPT (EG)
  42. 42. First Workshop in Egypt: Adaptation of CPGs 2009 (AFM-GIN-ADAPTE)
  43. 43. *12 M.Sc. Theses plus 1 Ph.D. thesis to produce 13 Adapted EBCPGs4 Finalized Adapted CPGs by CEBCPGs, HCQD-AUHs through MScTheses (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-AUHsthrough 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).
  44. 44. Alexandria CEBCPGs Adapted ADAPTE Methodsfor CPGs adaptation
  45. 45. 5 Finalized Adapted CPGs
  46. 46. Official website:http://www.alexmed.edu.eg/?page_id=1278 Last accessed 8/2012
  47. 47. https://www.facebook.com/pages/Alexandria-Center-for-Evidence-Based-Clinical-Practice- Guidelines/124300224291530?ref=hl
  48. 48. 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
  49. 49. Dr. Yasser Sami AmerM.Sc. Pediatrics, M.Sc. Healthcare InformaticsHospital Clinical Guidelines & Pathway General Coordinator, CEBCPGs, HCQD-AUHs, PrimaryContact Person for G-I-NDr. Hossam DhorghamM.Sc. Pediatrics, M.Sc. Healthcare ManagementFormer Healthcare Quality Coordinator, HCQD-AUHsFormer Head, Accreditation & Licensure Directorate, HCQD-AUHsEng. Ahmed MouradyCommunication & Electronics EngineerE-Learning Consultant,Former Local Project Manager, Modernization of AUHs in Smouha
  50. 50. Prof. Dr. Tarek OmarProfessor of Pediatrics & Ped. Neurology, AFM General Supervisor CEBCPGs & HCQD-AUHs. Former Head, AUHs Sector
  51. 51. Prof. Dr. Mahmoud El-ZalabanyProfessor of Pediatrics & Ped. Respiratory, Allergy & Immunology Former Dean, AFM Former Chairman, AUHs Board
  52. 52. G-I-N 2009 Lisbon G-I-N 2012 Berlin
  53. 53. Dr. Yasser Sami Amer MSc Pediatrics, MSc HC Informatics EBCPGs Advisor & Trainer