EVIDENCE-BASED CPGs FOR HEMATOLOGY - ONCOLOGY UNIT, KING SAUD UNIVERSITY HOPSITALS Saudi Arabia, Riyadh King Saud University Hospitals CPGs Committee Quality Management Dept CPGs Program By YASSER SAMI AMER

2. Evidence-Based
Clinical Practice Guidelines
For Staff of
Hematology-Oncology Unit
King Khalid University Hospital
2013
PART 1: Introduction
Instructor
Dr. Yasser Sami Amer, MBBCh, MSc
Pediatrician - HC Informatician
Member, G-I-N Adaptation Working Group/Steering Committee
CPGs General Coordinator, QMD, CPG Committee,
King Saud University Hospitals
KKUH/KAUH

3. Concepts & Definitions

4. Two Different Approaches to Evidence-Based
Practice (EBP)
Clinical Practice Guidelines (CPGs)
•“Top-down” approach
• Tell clinicians how to practice
• Favored by health care systems
Evidence-Based Medicine (EBM)
•“Bottom-up” approach
• Teach clinicians how to find answers
• Favored by medical educators

5. EBM definition
The integration of best research evidence
with clinical expertise and patient
values
Sackett et al 2000

6. 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)…

7. 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.
Clinical Practice Guidelines (CPGs)

8. CPGs New Definition
CPGs are “Statements that include
Recommendations intended to optimize
patient care that are informed by a
Systematic Review of evidence and an
assessment of the benefits and harms of
alternative care options”.
Committee on Standards for Developing
Trustworthy CPGs (IOM-AHRQ)

10. Rationale for CPGs
• Worldwide concerns about:-
▫ Unexplained variations in clinical practice
▫ Rising health care costs
▫ Exponential growth of information
• Aim of CPGs:-
▫ To facilitate more consistent, effective and
efficient practice and improve health
outcomes for patients

11. Clinical
Care GAP
Best
Practice

13. • Doctors
• Nurses
• Decision makers
• Patients
• Public

15. Producers Finders

16. • Specialized Onco societies:-
• National Comprehensive Cancer Network (NCCN) - USA
• American Society of Clinical Oncology - USA
• American College of Radiology - USA
• Oncology Nursing Society – USA
• Cancer Care Ontario – CAN
• Cancer Council Australia - AUS
• Saudi Oncology Society - KSA
• National CPGs agencies:-
 NICE - UK
 SIGN - UK

17. 7 Adapted CPGs
To MENA

18. ?

19. SIGN
Scottish
Intercollegiate
Guidelines Network
www.sign.ac.uk
CPG Producers:
National Agencies

20. CPG Producers:
National Agencies
NICE
National Institute for
Health & Clinical
Excellence
www.nice.org.uk

22. AHRQ
National Guideline
Clearinghouse
www.guidelines.gov

23. Guidelines
International
Network
(G-I-N)
www.g-i-n.net
Org. Member since
2009

24. Shaikh Bahamdan’s Research Chair for Evidence-
Based Health Care & Knowledge Translation
Member of G-I-N since Oct. 2009
Free access to International CPG Library of G-I-N

25. http://c.ksu.edu.sa/ebhc

26. http://ebhc.ksu.edu.sa/gin/index.html

29. PubMed
US National Library of
Medicine
National Institutes of
Health (NIH)

30. Some CPGs are only retrievable by
“Googling” them!

31. The Main CPGs Database websites we start searching:-
1- National Guidelines Clearinghouse
(NGC): www.guidelines.gov
2- Guidelines International Network (G-I-N) (International
Library): www.g-i-n.net
3- National Institute of Clinical and Health Excellence
(NICE): http://www.nice.org.uk/guidance/
4- Scottish Intercollegiate Guidelines Network
(SIGN): http://www.sign.ac.uk/guidelines/
5- DynaMed database: Evidence-based clinical
reference https://dynamed.ebscohost.com/
6- National Health and Medical Research Council - Australian
Government: http://www.nhmrc.gov.au/guidelines-
publications
7- Google/ Google Scholar: www.google.com

32. How do we react to
guidelines?

33. Read
Adopt
Adapt
Develop
CPGs ?

34. Topic
Team
Content
Search
FOUND NOT FOUND
Appraise Develop
AppraiseAdopt or Adapt
Implement
Evaluate impact

36. Adaptation of Clinical Practice Guidelines
The ADAPTE collaboration is an
international collaboration of CPG researchers, developers and
implementers. Their main aim is to develop and validate a
generic adaptation process that will foster valid and high-quality
adapted guidelines as well as the user’s sense of ownership of
the adapted guideline.

37. 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/

38. ©Copyright ADAPTE 2007

39. We identified 3 main ADAPTE steps:-
Adaptation Phase
Search & Selection of source CPGs
Health Questions (PIPOH)
AGREE II Instrument
Assess source CPGs quality
External Review
(Departmental Consensus)

40. CPG Scope: PIPOH Model
Patient (& disease characteristics)
Intervention(s)
Professionals (Target users)
Outcomes (purpose of the CPGs)
Healthcare settings (& context)
= Health/ Clinical/ Key Questions

42. Evidence Pyramid
MA
RCT
Cohort
Case control
Case series
Case report
Expert opinion
I
II
III
IV
A
B
C
LevelsofEvidence
GradesofRecommendations

43. How to assess of the quality of any CPG ?

44. Assess guideline
quality
ADAPTE TOOL 9 AGREE II
Instrument
23 items in 6 domains
7 point response scale
Domain scores
Recommendations

45. Considerations before a CPG
Assessment
• increase the reliability of the assessment
2 – 4 Appraisers
• in full and obtain all related information and
needed documents before undertaking the
AGREE II assessment ( to make a well
informed assessment)
Read CPG first

46. 23 Items in 6 Domains
USER’S MANUAL page 7
DOMAINS No. of Items
1 Scope & Purpose 3
2 Stakeholder Involvement 3
3 Rigour of Development 8
4 Clarity & Presentation 4
5 Applicability 3
6 Editorial Independence 2

47. 7. Systematic methods for E
search
8. Selection Criteria of E
9. Strengths & Limitations of E
10. Methods of Rs
11. Benefits , side effect and risks
in Rs
12. Evidence Links (Gs of Rs –
LoE)
13. External Review
14. Update Procedure
DOMAIN 3. RIGOUR OF DEVELOPMENT
Methods, literature search
strategy & appendices
+ inclusion/ exclusion criteria
+ Evidence tables, clinical
evidence, evidence description
(results), evidence
interpretation (discussion)
Methods, CPG Development
process
 same sections
+ Rs, Key Evidence
+ acknowledgements
+ CPG update, date of CPG

48. AGREE Enterprise website
http://www.agreetrust.org/

49. CPGs: 1 (or 2) documents
FIRST (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)

50. SECOND:
(Methodologist’s Version) ;
• Accessible from Libraries
of e.g.
Department, College of
Medicine, CPG
Committee, QMD, Authors
hip group,…etc. (Reference for
Replication & Documentation)
• Detailed description of the
CPG Adaptation process
with ALL relevant data.

51. Dissemination & Implementation
Nothing could be more
frustrating than producing
a CPG that is then ignored
by not being disseminated
nor implemented

52. Dissemination of CPGs
• External Review
• Full CPGs documents published on websites
• Implementation tools will also be published:
examples for choice:-
1. Quick Reference Guide (Summary Key Rs)
2. Clinical Algorithms (decision tree)
3. Clinical pathways (Integrated care pathways)
4. Order Sets
5. Patient Information (Education Guide) Arabic
6. Clinical Audit Tool
7. CPOE (Computerized Physician Order Entrty) = e-
SIHI (New HIS)
8. ICD – 10 Codes

54. • 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
Implementing Guidelines

55. Hematology-Oncology
Clinical Practice Guidelines
Subcommittee
Multidisciplinary !
TEAM WORK

56. TEAM
TOGETHER
EVERYONE
ACHIEVES
MORE

57. Participating/ promoting EBCPGs/ EBHC
WIN – WIN !MY
PATIENTS/
CLIENTS
MY
DEPARTMENT
MY
HOSPITAL

58. WIN – WIN !
Participating/ promoting EBCPGs/ EBHC
1) Improve our Life-long learning & Information Mastery
Skills
2) Improve our informed Clinical Decisions
3) Improve our patients (customers) outcomes
4) Improve our UG/ PG Teaching tools
5) Authorship of Publication (CPG Book/ Article)
6) Organizational Member in G-I-N
7) KSUHs EBCPGs Champions
8) Honoraria (Incentives),…and more!

59. Dr. Yasser Sami Amer
MSc Pediatrics, MSc HC Informatics
CPGs G. Coordinator,
QMD, CPGC, KKUH/ KAUH