international collaboration in guideline production prof. günter ollenschläger, chairman,...
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International Collaboration in Guideline Production
Prof. Günter Ollenschläger, Chairman, Guidelines International Network
Director, German Agency for Quality in Medicine
Helsinki, 10.11. 2004
www.g-i-n.net
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Happy Birthday Happy Birthday toto
DUODECIM‘sDUODECIM‘s
Current CareCurrent Care
GuidelinesGuidelines
www.g-i-n.net
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Membership
October 2004
Agency for Health Research & Quality AHRQ, USAgency for Quality in Medicine ÄZQ, DEAGREE CollaborationAssociation of Scientific Medical Societies AWMF, DEBasque Offi ce for HTA OSTEBA, ESBelgian Center for Evidence based Medicine CEBAM, BEBerlin Chamber of Physicians, DECenter for Health Policies and Services CPSS, ROCenter for Reviews & Dissemination York CRD, GBClinical Epidemiology Center Lausanne CepiC, CHDanish Center for Evaluation and HTA DACEHTA, DKDirectorate for Health and Social Aff airs, NODutch Association of Comprehensive Cancer Centres ACCC, NL Dutch College of General Practitioners NHG, NLDutch I nstitute for Healthcare I mprovement CBO, NLevidence.at - Austrian Ass.for Quality in Healthcare, ATEstonian Health I nsurance Fund, EEFederal Committee of Physicians and Sickness Funds FCPS, DEFinnish Medical Society Duodecim, FIFinnish Offi ce for HTA FI NOHTA, FIFlemish College of General Practitioners WVVH, BEGerman Federal I nstitute for Quality Assurance, DEHTA Unit, Ministry of Health Malaysia, MYI nstitute for Quality in Healthcare I QS, PTI talian Evidence- Based Medicine Group GI MBE, IJ .Briggs I nst.for Evid.Based Nursing&Midwifery, AUJ osep Laporte Library Foundation, Barcelona FBJ L, ESMinistry of Health- Refik Saydam Hygiene Centre Presidency, TRMoldovian Association of Perinatal Medicine, MDNat.Agency for Accred., Eval in Healthcare ANAES, FRNat. Board of Health and Welfare (Socialstyrelsen), SENational Federation of French Cancer Centres FNCLCC, FRNational I nstitute for Clinical Excellence NI CE, GBNational I nstitute of Clinical Studies NI CS, AUNational Kidney Foundation NKF, USNew Zealand Accident Compensation Corporation ACC, NZNew Zealand Guidelines Group NZGG, NZPolish I nstitute for Evidence Based Medicine PI EBM, PLProgram in Evidence- based Care, Cancer Care Ontario PEBC, CARegional Health Agency Emilia- Romagna ASR, IRoyal College of Nursing, GBRoyal College of Surgeons in I reland RCSI , I ERoyal Dutch Ass. of Physiotherapy KNGF, NLScottish I ntercollegiate Guidelines Network SI GN, GBSlovene Guidelines Group SGG, SISowerby Centre for Health I nformatics at Newcastle SCHI N, GBSpanish Network for Research on Guidelines REDEGUI AS, ESSwiss Medical Association FMH, CHTrimbos I nstitute – Neth.I nst.of Mental Health & Addiction, NLWorld Health Organisation Geneva WHO
52 Organisations /
26 Countries
Co-Chairs 2004/2005:
G.Ollenschläger, M. Mäkelä
www.g-i-n.net
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InternationalInternational Collaboration Collaboration in Guideline Productionin Guideline Production: :
ContentContent
• Background of the guideline movement
• Towards international networking in CPGs
• Aims and scopes of G-I-N
• International programmes and projects
www.g-i-n.net
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InternationalInternational Collaboration Collaboration in Guideline Productionin Guideline Production: :
ContentContent
• Background of the guideline movement
• Towards international networking in CPGs
• Aims and scopes of G-I-N
• International programmes and projects
www.g-i-n.net
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Guideline Movement: History
National Institutes of Health (US) – consensus development programme (1977)
Consensus Statements in SWE (81), NL (82), DK (83), UK (84), FI (85), NO (86)
Guideline programmes in several Western countries (1990s)
J. Burgers, Quality of CPGs, 2002
www.g-i-n.net
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Year of publication
20011996199119861981197619711966
nu
mb
er
of
refe
ren
ce
s
30000
20000
10000
0
Number of references in MEDLINE according to year of publications using MESH term
“guidelines or practice guidelines”
N. Klazinga, 2002 www.cpg2002.de
Clinical Practice Guidelines – a relevant international topic ?
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Generic reasons for interest in CPGsGeneric reasons for interest in CPGs
Economic crisis in health care and focus on cost containment
Growing concern about variation of care
Extra-professional interest: purchasers (governments, insurance companies) and patients ( consumer movement)
Professional organisations‘ interest: presenting the state of the art to colleagues, patients, policy makers
Feder, Burgers 2002 - www.cpg2002.de
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QualityQualityAssuranceAssurance
Quality Quality ImprovementImprovement
Biomedical ResearchBiomedical Research
Clinical TrialsClinical Trials
Outcomes and Effectiveness ResearchOutcomes and Effectiveness Research
Evidence Based InformationEvidence Based Information
Clinical Practice GuidelinesClinical Practice Guidelines
Quality MeasurementQuality Measurement
Guidelines aim at transferring Guidelines aim at transferring evidence into recommendations on best medical evidence into recommendations on best medical
practice as a basis of quality promotionpractice as a basis of quality promotion
J. Slutsky, US Guideline Clearinghouse, 2002 www.cpg2002.de
www.g-i-n.net
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InternationalInternational Collaboration Collaboration in Guideline Productionin Guideline Production: :
ContentContent
• Background of the guideline movement
• Towards international networking in CPGs
• Aims and scopes of G-I-N
• International programmes and projects
www.g-i-n.net
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Factors for Success of CPGs
The success and failure
of clinical practice guidelines depend on
• their quality and medical value,
• social, legal and ethical aspects involved,
• their implementation in daily practice.
Council of Europe Rec. No. R (01) 13
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Key Points for CPG‘s Acceptance
Clinical practice guidelines should
• link recommendations with underlying evidences
• deal with every day health care problems
• help professionals in providing best medical practice at minimal expenses
• give detailed description of best medical practice processes
Grol et al 1998
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Problems of Guidelines:Problems of Guidelines:
Quality Deficits and Conflicting RecommendationsQuality Deficits and Conflicting Recommendations
1. Missing links between recommendations and evidences
2. Few information on development process, sponsorship,
implementation tools
3. Cost-benefit-questions often excluded as topics
4. Conflicting guidelines on relevant topics
5. More academic recommendations than help for every day
practice
www.g-i-n.net
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Worldwide Trends in CPGs
From Toregional guidelines from
professional groupsnational guideline
programmes
informal consensus of experts
evidence-based systematic consensus
monodisciplinary multidisciplinary
focus on development focus on implementation
limited life-expectancy ‘living guidelines’
paper versions Internet
guidelines for clinicians patient versions and patient involvement
I. Kopp, J. Burgers, Edinburgh 2003
based upon Burgers, Grol, Klazinga, Mäkelä, Zaat for the AGREE Collab. Int J Qual Healthcare 2003
www.g-i-n.net
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Agree CollaborationAgree Collaboration
Research Project, Research Project,
sponsored by EUsponsored by EU
Council of Europe Council of Europe
CPG RecommendationCPG Recommendation
Inter. CPG NetworkInter. CPG Network
Towards International CPG Networking:Towards International CPG Networking:
From Research Partnership to Institutionalised Collaboration
• Research, training on high
quality CPG devel. / use
• Policy paper on CPG
standards
• CPG information,
dissemination, networking
www.g-i-n.net
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NETHERLANDSNETHERLANDS
DENMARKDENMARK
SWITZERLANDSWITZERLAND
FINLAND
ITALY
USA Canada New Zealand
GERMANY
SCOTLANDSCOTLAND
SPAIN
ENGLAND & WALESENGLAND & WALES
FRANCE
The AGREE The AGREE CollaborationCollaboration
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A P P R A I S A L O F G U I D E L I N E S f O R R E S E A R C H & E V A L U A T I O N
( A G R E E ) I N S T R U M E N T
T h e A G R E E C o l l a b o r a t i o n
S e p t e m b e r 2 0 0 1
1. Scope & purpose
2. Stakeholder involvement
3. Rigour of development
4. Clarity & presentation
5. Applicability
6. Editorial independence
Quality Aspects of Quality Aspects of Guidelines Guidelines
(Domains of the AGREE (Domains of the AGREE Instrument)Instrument)
www.g-i-n.net
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Agree CollaborationAgree Collaboration
Research Project, Research Project,
sponsored by EUsponsored by EU
Council of Europe Council of Europe
CPG RecommendationCPG Recommendation
Inter. CPG NetworkInter. CPG Network
• Research, training on high
quality CPG devel. / use
• Policy paper on CPG
standards
• CPG information,
dissemination, networking
Council of Europe Rec. No. R (01) 13
Towards International CPG Networking:Towards International CPG Networking:From Research Partnership to Institutionalised Collaboration
www.g-i-n.net
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Ethical,economicand legal
environmentDevelopment
Dissemination
Implementation
Monitoring
Evaluation
Review
Topic selection
Systematic Guideline Production and Use
PatientsProfessionalsPolicy makers
Optimal health care
Resources
Council of Europe: Rec 13, 2001
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Council of Europe Rec. No. R (01) 13
Chapter I – Current policy practices
Chapter II – Functions of guidelines
Chapter III – Methodology of guideline development
Chapter IV – Dissemination and implementation
Chapter V – Further practical, social, ethical and legal issues
Chapter VI – Guidelines and standards
Appendix 1 – Guideline programmes and clearing houses
Appendix 2 – Examples of levels of evidence in guidelines
J. Burgers, Quality of CPGs, 2002
www.g-i-n.net
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Council of Europe Rec. No. R (01) 13
J. Burgers, Quality of CPGs, 2002
The Committee of Ministers,
Recommends that the governments of member states :
.....
ii. promote international networking between organisations, research institutions, clearing houses and other agencies that are producing evidence-based medical information ;
.....
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March 2001: The idea of an institutionalised Guideline Network is introduced in the discussions of the AGREE Collaboration
October 2001: Council of Europe recommends networking in the CPGs field.
Jan-March 2002Survey on needs for a CPG network - SIGN (UK) / AEZQ (D).
November 2002: 11 “AGREE” partners from 8 countries consent on a constitution for The Guidelines International Network G-I-NG-I-N..
The G-I-N Story (1)The G-I-N Story (1)
www.g-i-n.net
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February 2003: G-I-N recognised as a Scottish Charity with 37 member organisations.
October 2004G-I-N has a membership of 52 organisations from 26 countries.
G-I-N’s “International Guideline Library” on www.g-i-n.net contains more than 2.600 guidelines and guideline documents.
The G-I-N Story (2)The G-I-N Story (2)
www.g-i-n.net
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InternationalInternational Collaboration Collaboration in Guideline Productionin Guideline Production: :
ContentContent
• Background of the guideline movement
• Towards international networking in CPGs
• Aims and scopes of G-I-N
• International programmes and projects
www.g-i-n.net
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Objectives of G-I-N
Quality improvement of healthcare
by promoting
systematic development, dissemination,
implementation and evaluation
of CPGs.
www.g-i-n.net
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“Implementability”
Development
Implementation
RESEARCH
Database of existing
guidelines
Database of guideline reviews/
comparisons
Database of guidelines in development
Libary of guideline
methodologies, tools, templates
Database of background
documentation
Collaboration(established members)
Promoting best practice
“Outreach”(new/prospective
members)
NETWORKING
INFORMATION
J. Miller, G. Ollenschläger, Berlin 2002 www.cpg2002.de
Need Assessment: Issues of G-I-N
www.g-i-n.net
273 3.5 4
Information sharing
Existing guidelines
Guideline reviews/comparisons
Patient guidelines
Implementation tools
Audit tools
Methodologies/development tools
Background documentation
Need Assessment: Key Projects of G-I-N
www.g-i-n.net
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Aims of G-I-N
• Improvement / harmonisation of CPG methodology• International collaboration
– to avoid duplication of effort – to facilitate information sharing, education, knowledge
transfer
• Prioritisation / support of CPG research • Maintenance of www.g-i-n.net (2.600 CPGs,
language specific training materials, ….)• Information and training via workshops,
conferences
www.g-i-n.net
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Components of G-I-N’s
Database-driven Website
CO
LD
FU
SIO
N
STRUCTUREDG-I -N
DATABASE
WEB SI TE
WEBSERVER
Users
G-I -NEDI TORI AL
TOOL
Writer, Editor, Reviewer
WEB SI TETEMPLATES
Developer
ww
w.g
-i-n
.net
Clinical Guidelines...- Database- Background documents - Topic collection- Training material- Implementation tools- Language groups - CPG News
www.g-i-n.net
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G-I-N‘s Strategic Direction (1)
Continuously updating and enhancing the INTERNATIONAL GUIDELINE LIBRARY (www.g-i-n.net)
Developing RECOMMENDATIONS for CPG use (f.e. for the adaptation of CPGs between countries)
Developing international programmes on CPG topics:> Background documentation / evidence tables> Consumers/ patients and evidence > Dissemination and implementation> Electronic decision support> Guideline research> Linking CPGs with reviews (Cochrane, HTA, CME, Qual.Promot.)
www.g-i-n.net
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G-I-N‘s Strategic Direction (2)• Joint Projects between member organisations:
– Language specific CPGs and training materials: e.g. French, German, Dutch – Regional networks: e.g. Nordic countries, – CPG Adaption– CPG Appraisal using the AGREE Instrument– Standardised CPG formates– Living CPGs– Training by regional workshops
• Joint Projects with external partners– G-I-N / Cochrane– G-I-N / INAHTA – G-I-N / GRADE
• Annual Conferences Edinburgh (UK) 2003, Wellington (NZ) 2004, Lyon (F) 2005, Toronto (CA) 2006
www.g-i-n.net
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InternationalInternational Collaboration Collaboration in Guideline Productionin Guideline Production: :
ContentContent
• Background of the guideline movement
• Towards international networking in CPGs
• Aims and scopes of G-I-N
• International programmes and projects
www.g-i-n.net
34
Systematic CPG Adaptation
Find the guidelines
Appraise the guidelines
Analyse the content
Permission to adapt
Look at the gaps
Look at the sources
What are the cultural and consumer issues
DevelopRecommendations using CJF
Z. Fras 2002 – C.Marshall 2003, G. Ollenschläger / R.Schaffler2004
www.g-i-n.net
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CPG Short Version
Key Information + Recommendations
Lev
el
1
CPG Long Version
Level 1 + Judgements + Evidence Tables
CPG Sources
Evidence (e.g.Pubmed, HTA, G-I-N)
Lev
el
2L
evel
3
Link
Link
Interactive CME Tool:
WWW Education
Patient Information
Key Information + Comments + Sources
Link
Quality Measures
Indicators + Criteria + Sources
Guideline Implementation
Linking CPGs with CME, Pat.-Info, Qual.Promotion
www.versorgungsleitlinie.de
www.g-i-n.net
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Worldwide Trends in CPGs
From Toregional guidelines from
professional groupsnational guideline
programmes
informal consensus of experts
evidence-based systematic consensus
monodisciplinary multidisciplinary
focus on development focus on implementation
limited life-expectancy ‘living guidelines’
paper versions Internet
guidelines for clinicians patient versions and patient involvement
I. Kopp, J. Burgers, Edinburgh 2003
based upon Burgers, Grol, Klazinga, Mäkelä, Zaat for the AGREE Collab. Int J Qual Healthcare 2003
www.g-i-n.net
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G-I-N Membership
• Organisational Members– non-profit-distributing bodies / organisations– working in the CPG field– committed to adopting evidence-based practice – transparent about its sources of funding
• Associate Members– Any other body or association – Any individual who is active in the CPG field
(Only members get full access to the International Guideline Library)
www.g-i-n.net
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What are CPGs ?
...systematically developed statements
to assist important professional and patient
decisions about appropriate health care
for specific clinical circumstances.
Institute of Medicine: • Clinical Practice Guidelines: Directions for a New Program. (1990)• Guidelines for Clinical Practice: From Development to Use. (1992)• Setting Priorities for Clinical Practice Guidelines. (1995)Washington DC: National Academy Press, 1995.
Council of Europe Rec. No. R (01) 13