The need for treatment guidelines and the development of the University of Nigeria Teaching Hospital (UNTH) breast cancer management protocol

1. TREATMENT
GUIDELINES- A
NECESSITY
BY DR LASEBIKAN NWAMAKA

2. OUTLINE
DEFINITION
IMPORTANCE
UNDERSTANDING GUIDELINES
BENEFITS
LIMITATIONS
THE UNTH EXPERIENCE

3. WHAT ARE GUIDELINES
“……systematically
developed statements to
assist in practitioner and
patient decisions about
appropriate health care for
specific clinical

4. ACCORDING TO AHRQ

5. IMPORTANCE OF
GUIDELLINES
 To improve the quality of care
 Assess the clinical and cost effectiveness of
treatments and ways of managing a particular
condition
 Are based on the best available research evidence
and expert consensus
 Are developed using recommended methods that are
robust and transparent
 As a reference when wide regional variations exist in
managing a condition
“…..clinical
practice
guidelines are
becoming more
prominent as a
key metric of
quality
healthcare…..”

6. BENEFITS…
 Guidelines help clinicians
translate best evidence
into best practice. A well-
crafted guideline promotes
quality by reducing
healthcare variations,
improving diagnostic
accuracy, promoting
effective therapy, and
discouraging ineffective –
or potentially harmful –
interventions.

7. UNDERSTANDING
GUIDELINES
USEFUL
TOOLS
- AGREE
- COGS
 Guidelines are one way of implementing evidence into
practice. They can serve as a guide to best practices, a framework
for clinical decision-making, and a benchmark for evaluating
performance.
 Guidelines benefit patients through better outcomes, fewer
ineffective interventions, greater consistency of care, and by
creating secondary implementation materials (pamphlets, videos,
etc.).
 Clinicians can use guidelines to make better decisions, initiate
quality improvement efforts, prioritize new research initiatives, and
support coverage or reimbursement for appropriate services.
 Conversely a flawed guideline could significantly harm both
patients and clinicians, thereby mandating sound methodology as

8. Potential limitations of guidelines
 Wrong recommendation- guideline developers
may err in determining what is best for patients for
three important reasons.
 Firstly, scientific evidence about what to
recommend is often lacking, misleading, or
misinterpreted..
 Secondly, recommendations are influenced by the
opinions and clinical experience and composition
of the guideline development group
 Thirdly, patients’ needs may not be the only

9. Potential harms to healthcare
professionals
 Flawed clinical guidelines harm practitioners
by providing inaccurate scientific information
and clinical advice, thereby compromising the
quality of care. They may encourage
ineffective, harmful, or wasteful interventions

10. THE UNTH EXPERIENCE
THE CANCER CARE CONTINUUM

11. THE PROCESS-Conception –
Conclusion…..9months
-AGREE
-NICE
-NCCN
 DEVELOPED USING RECOGNIZED
METHODS THAT ARE
ROBUST,OBJECTIVE, SCIENTIFICALY
VALID, CONSISTENT AND WORKABLE IN
UNTH.
 DEVELOPMENT INVOLVED ALL
IDENTIFIED MULTISECTORIAL AND
MULTIDISCIPLENARY STAKEHOLDERS

13. THE SCOPE
Purpose of the scope
provide an overview
of what the guideline
will cover. It also
identifies the
population involved,
key clinical issues
and itemizes main
outcome of
intervention.
UNTH DRAFT SCOPE
 “the clinical management of breast cancer
will operate using a framework of decision
making tools spanning the entire cancer
care continuum, from cancer
prevention/screening to end of life care in
keeping with global best practices. The
expected outcome of the development of
this protocol includes;
 To improve the quality of care offered, as
recommendations are based on the best
available research evidences and expert
consensus
 Improve overall survival and other health
monitoring indices including quality of life
 To assess the clinical and cost
effectiveness of treatments and ways of
managing breast cancer”

14. Examples of key issues and questions that could be included in draft scopes for consultation
Identify Issues relating to services
- develop key questions relating to services
Identify Issues relating to interventions
-develop key questions relating to interventions
Identify Issue relating to experience of people using services
- develop key question relating to experience of people using services
Identify key question relating to health inequalities and equality
Are there population groups, including those sharing a protected characteristic, who may
be affected by poor access to service or treatment?

15. INAUGURATIO
N OF THE
GUIDELINE
DEVELOPMEN
T GROUP :
-
DEVELOPMENT OF
REVIEW QUESTIONS-
USING “PICO”
DEFINE REVIEW
STRATEGY
REVIEW RESEARCH
EVIDENCE AND
APPLYING TO UNTH
WRITING UP THE
GUIDELINE
RECOMMENDATIONS
THE PROCESS

16. 1st Phase – January 28th 2017
• Initiation of project
• Organization of protocol development committee and inauguration of
subcommittees
• Decide on review questions
Lay out plans/methodology for decisions reached
2nd Phase - 30th January- 31st March 2017
• Guideline Development for each subcommittee
• Literature Search/call for evidence from stakeholders
• Development of draft guideline( 20th March- 31st March)
3rd Phase – 3rd April – 22nd April
• Consultations/ stakeholders review draft document (3rd – 7 thApril)
• Guideline revised in response to stakeholder comments (10th – 14th April)
• Finalized guideline sent to all stakeholders ahead of publication (17th –
20th April)
WORKPLAN

17. STRENGTHS
 MULTIDISCIPLENARY
PLATFORM.
 DEDICATED,
KNOWLEDGEABLE
PROFFESSIONALS
WILLING TO PARTNER
TOGETHER
 INSTITUITIONAL
SUPPORT
 IT Support-whassap
platform

18. WEAKNESS/CHALLENGES
 DIVERGENT VIEWS
 UNMET TIMELINES
 POOR COMMITMENT
FROM IDENTIFIED
STAKEHOLDERS
 LIMITATION OF
RECOGNIZED BEST
STANDARD OF
CARE TREATMENT
OPTIONS
 CARING FOR THE
ECONOMICALY
DISADVANTAGED
PATIENTS

19. OPPORTUNITIES
 EXPAND CONTENT
 EXPAND
COVERAGE TO
INCLUDE OTHER
COMMON
CANCERS AND
ECONOMIC
EVALUATION

20. MEASURABLE TIMELINES
 IMPLEMENTATION
 TRACK EARLY
REFERRALS
 NAVIGATION
 MULTIDISCIPLENA
RY MEETING
 EARLY REFERRAL
TO PALLIATIVE
CARE
 TREATMENT
OUTCOME

21. RESULTS OF SURVEY
Clinical
reminde
r
15%
Targted
educati
onal or
training
progra
ms…
Mentori
ng
17%
Addition
al
resourc
es
10%
Presen
ce of
guidelin
e
champi
on…
Support
ive
leaderrs
hp
8%
pocket
version
s
17%
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
AxisTitle
RESPONDANTS FOR
USE OF GUIDELINES
1
2

22. · Pre-emptive identification of potential barriers of recommendations, and a priori generation of
solutions to address them by the guideline development group. At a minimum the guideline group
should be aware of the potential barriers;
· Use of behaviorally specific language in the guideline
· Use of multiple formats and channels for guideline dissemination based on preferences of the
target group of health care practitioners;
· Development of educational resources adapted in content, and vehicle to each target group of
health care practitioners;
· Identification of the resource implications of recommendations, ensuring their availability before
starting;
· Use of data collection tools (for example, simple audit templates).
From: Gagliardi et al. How can we improve guideline use? A conceptual framework of
implementability. Implementation Science 2011, 6:26.
Strategies to support guideline uptake

24. THANK YOU
FOR
LISTENING