Creating and adapting a high-quality national

clinical guideline with limited resources

Creating and adapting a high-quality national

clinical guideline with limited resources

Authors:

Mario TristanAnggie RamírezBrian Alper

Jonas R. Te Paske

August 25th 2012GIN Conference Berlin 2012

Authors:

Mario TristanAnggie RamírezBrian Alper

Jonas R. Te Paske

August 25th 2012GIN Conference Berlin 2012

Disclosure of Interests (last 3 years)

< Mario Tristan, Anggie Ramírez, Jonas R. Te Paske>No personal or professional situation that might

reasonably be expected to affect views on the subject on which we are presenting.

< Brian Alper >Editor-in-Chief, DynaMedMedical Director, EBSCO Publishing (full-time employee)

Costa Rica health authorities requested producing Clinical Guidelines for breast cancer

treatment and for early detection.

They said “We need IN IT the NEXT six

months” !!!

June 2010!!!

The Challenge

“…he argues that using standard methods for updating the evidence was similar to reinventing the wheel because some one else is doing or has done what you are

trying to do...”

“…OUR FIRST scratch paper ABOUT the METHODS .......”

Search

DynaMed is a point-of-care clinical reference

• Created by physicians and other health care

professionals.

• > 3,200 clinically organized topics.

• Evidence-based:

• Systematic 7-step methodology

• Summarization and synthesis of best evidence and

guidelines

• Updated daily.

• Rapid use: standardized templates, outline

format, linking.

• Available via internet, mobile devices, and

webservices.

Defining Evidence-Based for a Clinical Reference

For DynaMed “evidence-based” requires 7 steps:

1.Systematically identifying all applicable evidence.

2.Systematically selecting the best available evidence from

that identified.

3.Systematically evaluating the selected evidence (critical

appraisal).

4.Objectively reporting the relevant findings and quality of

the evidence.

5.Synthesizing multiple evidence reports

6.Deriving overall conclusions and recommendations from the

evidence synthesis.

7.Changing the conclusions when new evidence alters the best

available evidence.

Fig 1: Updating curves for relevant evidence (128 systematic reviews) by point of care information summaries (log rank χ2=404, P<0.001).

• ©2011 by British Medical Journal Publishing Group

Levels of evidence in DynaMed

Based on Strength Of Recommendation Taxonomy (SORT)

Level 3 (lacking direct) evidence•No comparative data.•No clinical outcome.

Level 2 (mid-level) evidence•Comparative data for clinical outcome.•Any risk of bias identified on critical appraisal.

Level 1 (likely reliable) evidence•Comparative data for clinical outcome.•No substantive risk of bias identified.•Meets explicit criteria (valid methodology, adequate results) for type of clinical question (interventional, diagnostic, prognostic).

Evidence Grading

Guía de Práctica Clínica Oncoguía de Cataluña (2008), Spain.EBM Breast Cancer Guideline. ID: ebm00543 (025.023). Duodecim Medical Publications, (2009), Finland.Guideline: Management of Breast Cancer in Women 84 SIGN (2007), Scotland.Evidences Summaries Breast Cancer treatment DynaMed (2010).Evidences Summaries Breast Cancer Duodecim Medical Publications (2010), Finland. American Joint Committee on Cancer Staging Handbook. 7th Edition. (AJCC ,2010). National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology (NCCN Guidelines™ 2010).Original research trials

Clinical Guideline was a excellent example for us:

“Evidence based clinical guidelines for preventing the thromboembolic venous

diseases in different medical conditions”SOCIEDAD ESPANOLA DE TROMBOSIS Y HEMOSTASIA SOCIEDAD ANDALUZA DE

ANGIOLOGIA Y CIRUGIA VASCULAR 2007

Recommendations validations by multidisciplinary experts

Recommendations validations by multidisciplinary experts

Evidence Body

Evidence Body

RecommendationRecommendation

9 Likert Scale (RAND/UNCLA)

9 Likert Scale (RAND/UNCLA)

ResultsExternal peer reviewers and evaluators

Nacional 94%

International 96%

ProductsProducts

CPG for Breast Cancer Treatment

Breast Cancer Treatment Guideline for patients

CPG for Breast Cancer Treatmentpocket version

Algorithms

Results

Time to complete:

Effort spent:

Currency:

Comprehensiveness:

User feedback:

5 months for training + evidence analysis

3 FTE for 6 months

Most current content of 16 CPG`s

All studies on MEDLINE + EMBASE search captured by DynaMed

Clinicians changed from resistors to supporters

Lessons learned

• Usefulness of adapting from other

guidelines.

• Usefulness of DynaMed for finding

current, comprehensive, appraised,

evidence.

• Efforts needed to map SORT to GRADE.

• Usefulness of including evidence in

stakeholder feedback.

QuestionsQuestions