NCGCNCGC National Clinical Guideline CentreNational Clinical Guideline Centre

16.02.11

Ian BullockJill Parnham

Knowledge (evidence) translation and utilisation, leading to

improved patient outcome

‘A whole healthcare systems approach’

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NCGCCommissioned by DH & NICE20+ guidelines / QS in developmentBudget of £4.56 million (2,818,008 OMR)~70 staff – specialist expertise EMBInter related work with RCP Clinical Standards

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UK STAKEHOLDERS contextUK STAKEHOLDERS context

PatientsPatients

ProfessionsProfessions NHSNHS

IndustryIndustry

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NCGC Vision that is:• Focussed on quality (Quality Standards)• Patient centred (High political priority)• Clinically driven (Professionally important)• Flexible (Diverse work programme) • About valuing people (Always about people)• Promoting continuous improvement (With

growth inevitably comes increased responsibility)

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The quality spiral

Largest EB guideline centre in world

Commissioned by DH / NICE

14 guidelines in development, rolling programme

XXX scoping

Full guideline takes XXX months

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National Clinical Guideline Centre Formed on April 1st 2009 Merger of 4 National Collaborating

Centres - Primary Care (RCGP) - Chronic Conditions (RCP) - Nursing and Supportive Care (RCN) - Acute Conditions (RCS) Hosted by Royal College of Physicians

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Guideline Development• Multidisciplinary group• Supported by technical team

(researchers; health economists; information scientists and project managers)

• Technical team are members of the group with voting rights

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Developing clinical guidelines1. Scoping: Identify and refine the subject area2. Convene multi disciplinary guideline

development groups including patients/carers3. Develop clinical questions: process started4. Obtain and assess the evidence about the clinical

questions5. Analyse and present evidence to GDG6. Translate the evidence into recommendations

(clinical guideline)7. Arrange external review of the guideline

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Mark Twain

‘Synergy — the bonus that is achieved when things work together harmoniously.’

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Answering the clinical questions Each recommendation needs to relate to a questionEach question has to be addressed with a systematic review of the evidenceEach systematic review requires

– A question protocol listing inclusion/exclusion criteria– A comprehensive literature search– Each study reviewed to be quality assessed using NICE forms*– Each included study to have data extracted into an evidence table– Each outcome from each question to be synthesised into a meta-

analysis (where possible)*– The collated estimate for each outcome to be assessed using GRADE*– Results written up in the guideline

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Types of questionsAetiology/causationDiagnosis/screeningPrognosisEffectiveness (therapy, clinician, organisation)Cost-effectivenessHarmVariation in practiceEquityExperience and meaning

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General structure of a clinical question

The acknowledged structure is known as PICO–Population–Intervention (or exposure for

prognosis)–Comparison (optional) –Outcome

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PICO Structure – effectiveness examplePICO Ask yourself Example

Population (P) (patient/condition)

How would I describe the group(s) of patients?

People aged 12 or over who have ......

Intervention (I) (drug, procedure, diagnostic test, exposure)

Which main intervention, prognostic factor, exposure …

xxxx or xxxx plus xxxxx

Comparison (C) (optional)

What is the main alternative to compare with the intervention?

the same drug alone

Outcome (O) What can I hope to accomplish, measure, improve or affect?

Time to resolution of symptoms

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NICE principles – include social value judgements

• Need evidence to recommend an intervention (can make ‘research only’ recommendations)

• Clinical and cost effectiveness• Good use of resources• Can make recommendation for a subgroup of

population if clear evidence for effectiveness• Involve and respond to stakeholders• Equalities• Transparency

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How evidence presented to GDG

1. Details of study – where, population groups, interventions etc

2. Quality assessment – checklists/GRADE3. Results – varies e.g. narrative, forest plots4. Interventions – GRADE profiled5. Meta-analysis where possible6. Health economic modelling outcomes ‘evidence’

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Why consider cost-effectiveness?The NHS does not have enough resources to do everythingIf it spends more on one thing, it has to do less of something elseCould we do more good by spending money differently?Prioritise interventions with a high health gain per £ spent

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Why are recommendations difficult in evidence based guidelines?• No evidence• Poor evidence• Doesn’t answer the question• Wrong patient group• Wrong comparator• Wrong outcome

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Options when evidence poor/no evidence

Extrapolate if possible (indirect evidence)Expert group discussion (informal consensus)VoteFormal consensus decision makingTransparency and acknowledgementNo recommendation

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Guideline Development Timeline20102010 20112011 20120122

QuartersQuarters QuartersQuarters QuartersQuarters

11 22 33 44 11 22 33 44 11 22 33 44

ScopingScoping

DevelopmenDevelopmentt

ConsultationConsultation

ValidationValidation

PublicationPublication

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NICE (NCGC) and Quality Initiatives2000 -2006

– Focus on guidance, not indicators or standards• Clinical Guidelines; Public Health Guidance and Technology

Appraisals – Developed audit tools directly based on NICE guidelines

2008– Labour Government’s Next Stage Review– Expanded role for NICE in Quality Indicator Development

• NICE-managed QOF for general practice• NICE to develop Quality Standards

2010 (July)– Coalition Government’s Health White Paper

• NHS Outcomes Framework• NICE Quality Standards seen as central to delivering this

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What are Quality Standards? Quality statements

– Descriptive statements (5 to 10) of the critical infra-structural and clinical requirements for high quality care as well as the desirable/expected outcomes

– Key points on care pathwayQuality measures

– Structure, process (and outcome) measures – “High Level” Quality Indicators

• Use at local level as audit criteria• Inform subsequent national indicator development

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What are Quality Standards? Audience descriptors

– A description of what the quality standards mean for different audiences• Service providers• Health and Social Care Professionals• Commissioners• Patients

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What is the purpose of Quality Standards?• To make it clear what high quality care is

by providing definitions of clinical and cost-effective care

• To support benchmarking of performance• To provide information to patients and

the public about the quality of care they can expect

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NICE Quality Standards programmeAims

– To develop Quality Standards for topics selected by the National Quality Board (NQB)/ NHS Commissioning Board on an annual basis

– To offer clarity about what high quality care looks like across 3 dimensions of quality ensuring:

• Patient care is effective• Patient care considers patient experience• Patient care is safe

– To develop a comprehensive set• 150 to be developed over 5 years

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Current Work Programme2009-2010 – Pilot Phase 2010-2011

StrokeStroke COPDCOPDDementia CKDCKD

VTE – PreventionVTE – Prevention Diabetes (Adults)Diabetes (Adults)Published May 2010 Depression (Adults)Specialist Neonatal Care End of Life CarePublished Autumn 2010 GlaucomaGlaucoma

Heart FailureHeart FailureBreast Cancer

Alcohol DependenceAlcohol DependenceKey: Patient Experience (x2)Patient Experience (x2)NCGC producedNCGC produced

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Overview of Quality standards development

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Quality Standard

Evidence Source

1) Policy Drivers2) Audit evidence

on current care

NICE quality standard- Quality statements- Measures

Clinical Guideline Recommendations

- NHS Evidence Accredited Sources

1. Key Department of Health and other documents

2. National Clinical Audits- Current clinical practice

(areas requiring improvement)

NICE quality standards

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NICE Stroke Quality StandardScope of Quality Standard:

– Care provided to adult stroke patients • diagnosis and initial management, acute phase care,

rehabilitation and long-term management

Policy context:– Department of Health “National Stroke Strategy” (2007)– Department of Health “Reducing Brain Damage: faster access to

better stroke care” (2005)

Key development sources:• Royal College of Physicians “National Clinical Guideline for

Stroke” (2008) which incorporates NICE CG68 Diagnosis and initial management of acute stroke and transient ischaemic attack (2008)

• National Sentinel Audit for Stroke (2000 – ongoing)

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Example quality statement for strokeIn a high quality service for patients with stroke ...

Patients with acute stroke receive brain imaging within 1 hour of admission if they meet any of the indications for immediate imaging (QS2)

Relevant CG recommendation–Brain imaging should be performed immediately (within 1 hour) for people with acute stroke if any of the following apply …

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Example of quality measure for strokeStructure: Evidence of local

arrangements to ensure patients with acute stroke receive brain imaging within 1 hour of arrival at the hospital if they meet any of the indications for immediate imaging.

Process: Proportion of patients with acute stroke who meet any of the indications for immediate imaging who have had brain imaging within 1 hour of arrival at the hospital. [Numerator & Denominator defined]

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What the quality statement means for each audience – stroke example

Service providers ensure facilities and protocols are available for patients to receive brain imaging within 1 hour of arrival at the hospital if they meet any of the indications for immediate imaging.

Health care professionals ensure that patients under their care with acute stroke receive brain imaging within 1 hour of arrival at the hospital if the criteria for immediate imaging are met.

Commissioners ensure that services they commission enable patients to receive brain imaging within 1 hour of arrival at the hospital if they meet any of the indications for immediate imaging.

Patients with acute stroke with any of the indications for immediate brain imaging can expect to receive this within 1 hour of arrival at the hospital.

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Data SourceStructure: Local data collection.Process: Trusts can collect data via the

Sentinel Stroke Audit, Hospital Episode Statistics (HES) data and through local data collection.

There exist existing quality assured indicators Sentinel Stroke Audit CV02

– Proportion of stroke patients given a brain scan within 24 hours of stroke

DH WCC Assurance Framework Acute 36 – Percentage of stroke admissions given a brain scan

within 24 hours

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How will quality standards be used?Used to drive up the quality of health care

For use by:– patients, the public, health and social care professionals,

commissioners and service providersCan be used in:

– commissioning, payment mechanisms and incentives schemes such as CQUIN, Quality Accounts and Care Quality Commission special reviews

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Measurement is crucial and can be linked to consultant appraisal

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Stroke quality spiral

EpidemiologyPolicy contextSetting standardsMeasuring standardsImproving quality of clinical care

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UK stroke epidemiology

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Stroke

Stroke is one of the top three causes of death

and the largest cause of adult disability in

England, and costs the NHS over £3 billion

(1,854,274,200 OMR) a year.

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Stroke

In 2008-09, the direct care cost of stroke was at least £3 billion annually, within a wider economic cost of about £8 billion (4,945,200,233 OMR).

Without preventative action, there is likely to be an increase in strokes as the population ages.

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Stroke

One in four people who have a stroke die of it.

There are approximately 110,000 strokes and 20,000 TIAs per year in England.

300,000 people are living with moderate to severe disabilities as a result of stroke.

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National stroke picture

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NICE Acute Stroke Guideline

Took 24 months to develop18 experts plus technical teamRigorous and systematic methodologyPublished 2008Looked at thousands published papersBased recommendations upon 200 key

papersMade 62 EB recommendations

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Stroke care pathway

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Stroke care pathway

‘Time lost is brain lost’

Pathway derived from the evidence based NICE guideline

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Guidelines

The NICE guideline (July 2008) covers interventions in the acute stage of a stroke (‘acute stroke’) or transient ischaemic attack (TIA).

Most of the evidence considered relates to interventions in the first 48 hours after onset of symptoms, although some interventions up to 2 weeks are covered.

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Guidelines

The RCP Intercollegiate Stroke Working Party (ICSWP) National Clinical Guidelines for Stroke (published July 2008) includes all of the recommendations from this NICE guideline.

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National stroke guidelines

Nested within

Setting the standard

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Guidelines and audit

National guidelines provide clinicians, managers and service users with summaries of evidence and recommendations for clinical practice.

Implementation of guidelines in practice, supported by regular audit, improves the processes of care and clinical outcome.

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National stroke audit

In the UK, the National Sentinel Stroke Audits have documented changes in secondary care provision over the last 10 years, with increasing numbers of patients being treated in stroke units, more evidence-based practice, and reductions in mortality and length of hospital stay.

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DoH National Stroke Strategy

This strategy sets out what should be done to achieve the necessary revolution in stroke care.

It set an ambitious agenda to deliver world-class stroke services, from prevention right through to life-long support .

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The Strategy is intended to provide ….a quality framework against which local

services can secure improvements to stroke services

advice for commissioners in the planning, development and monitoring of services;

does not act as a clinical guideline – the NICE & RCP guidelines fulfil these roles.

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Strategy example…..the link between policy and audit

Stroke unit quality: stroke unit care is the single biggest factor that can improve a person’s outcomes following a stroke. Successful stroke units are built around a stroke-skilled multidisciplinary team that is able to meet the needs of the individuals. How does your local unit rate on the Royal College of Physicians’ National Sentinel Stroke Audit?

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RCP national stroke audit

Acknowledgement to Alex HoffmanVoluntary participationSnapshot every 2 yrsOrganisational & clinical auditHigh quality data submitted on a web

based toolOver 70 data itemsAudit annual budget £240k (148,321.40

OMR)

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Stroke audit

100% UK hospital participation rate159 trusts (201 sites covering 249

hospitals) N=11,353 pts

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Stroke audit

Run by cliniciansIndividual hospital reports with results

benchmarked against national averages

Reports to Department of Health and Parliament

Extensive media coverage

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Organisational audit criteria

Presence of a stroke unitQuality of stroke unitAll patients admitted to a stroke unit Staffing ratios on a stroke unitMultidisciplinary team workPatient involvementTIA servicesThrombolysis service and coverage

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Clinical audit criteria

Delay to scanningPrompt assessmentsTherapy doseAntithromboticsCommunication with agencies and

patients

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What audit does wellNational audit with 100% participation compares

structure and process against evidence based standards for the UK and provides:– a snapshot of care and organisation or services– a national benchmark– hospitals and patients and managers comparable

information – a starting point for improving care– an indication of the rate of change across the country and

between regions and hospitals since 2001

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Evolution of evidence 2004 - 08

2008 NICE and RCP guidelines

“All patients with suspected stroke should be admitted directly to an acute stroke unit”

Admitted to a stroke unit:

2004 = 46%

2008 = 74%

2010 = 88%

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Stroke unit service

An acute stroke unit is a discrete area in the hospital that is staffed by a specialist stroke multidisciplinary team. It has access to equipment for monitoring and rehabilitating patients. Regular multidisciplinary team meetings occur for goal setting.

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Hyper acute serviceSpecialist hyper-acute stroke units bring experts and equipment under one roof to provide:rapid assessment – a patient must arrive in a specialist stroke ward, no more than two hours after having a stroke, and be assessed by a specialist;access to a CT scan within 30 minutes of arrival;early thrombolysis, if the scan shows they are needed, within three hours of having a stroke (and 30 minutes of arrival);24/7 monitoring in a high dependency bed; anda multi-disciplinary specialist team on call 24/7; including consultants, specialist nurses and therapists.

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Audit – stroke unit

The proportion of stroke patients who spend more than 90 per cent of their hospital stay on a stroke unit has increased from 51% in 2006 to 58% in 2008 and reached 70% 2010.

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Audit – time to stroke unit

In 2008, only 17% of stroke patients reached the stroke unit within 4hrs of their arrival at hospital. By 2010 this has more than doubled to 38% but there is massive room for improvement.

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Thrombolysis rate

1.8% in 2008 5% in 2010

This should increase further as more areas of the country start providing 24 hour a day seven day a week hyper acute stroke services.

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Alteplase

Treatment must be started within 3 hours of onset of the stroke symptoms and after prior exclusion of intracranial haemorrhage by means of appropriate imaging techniques.

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NICE recommendations

Alteplase is recommended for the treatment of acute ischaemic stroke when used by physicians trained and experienced in the management of acute stroke. It should only be administered in centres with facilities that enable it to be used in full accordance with its marketing authorisation.

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Alteplase

Alteplase should only be administered within a well organised stroke service with:staff trained in delivering thrombolysis and in monitoring for any associated complicationsimmediate access to imaging and re-imaging, and staff appropriately trained to interpret the images.

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Audit – AF and stroke

~12,500 strokes a year directly attributable to AF.

NICE guideline recommends that the most effective treatment, for patients with AF post-stroke, is with warfarin.

However………

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2011 pre publication findings

People admitted with stroke:Only 27% who were recorded as having AF before their stroke were taking warfarinFailure to anticoagulate large numbers of people at risk of stroke due to AF

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Audit

26 standards used to calculate scoreIMPORTANTLY over the 10 years of audit

we have been able to identify 9 key indicators, a minimum dataset

Known as a ‘bundle of stroke care’

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Minimum dataset

Following the third round of audit in 2002 a minimum dataset was selected to best represent the total clinical process for each hospital. Between 2006 and 2008 this was reduced to 9 key indicators in consultation with the Department of Health and the Healthcare Commission.

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9 key audit indicators1 Patients treated for 90% of stay in a Stroke Unit

2 Screened for swallowing disorders within first 24 hours of admission

3 Brain scan within 24 hours of stroke

4 Commenced aspirin by 48 hours after stroke

5 Physiotherapy assessment within first 72 hours of admission

6 Assessment by an Occupational Therapist within 4 working days of admission

7 Weighed at least once during admission

8 Mood assessed by discharge

9 Rehabilitation goals agreed by the multi-disciplinary team

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Audit changes over timeNo Quality indicator % compliance 2004 2006 2008 2010

1 Pts treated for 90% stay in stroke unit

- 51 58 70

2 Swallowing scrned 24hrs admission 63 66 72 83

3 Brain scan 24hrs of stroke 59 42 59 70

4 Commenced aspirin 48 hrs of stroke 68 71 85 93

5 Physio assess within 72hrs admission 63 71 84 91

6 OT assess within 4 WDs admission - 49 66 83

7 Weighed during admission 52 57 72 83

8 Mood assess by discharge 47 55 65 80

9 MTD rehab goals agreed 68 76 86 94

Average for 9 indicators - 60 72 83

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% pts with all 9 indicators

This “bundle” of indicators describes the percentage of patients receiving all 9 key standards nationally and within each hospital trust

Individual hospital results providedNational data publically available

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NCGC work leading to Oman Quality Improvement

Funded, published and acclaimed work informing health care decisions in another health care context is possible:

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PARIHS: The theoretical framework

STROKESTROKE

Oman policy and

Oman policy and

professionals

professionals

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Information and knowledge upon whichdecisions about care are based:1. Research2. Clinical Experience3. Patient Experience4. Local Information/Data

The Nature of Evidence

http://www.parihs.org/pages/core_parihs_papers.html

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The process is about:1. Evidence2. Context3. Culture

Evidence translation leading to utilisation

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The quality spiral

Largest EB guideline centre in world

Commissioned by DH / NICE

14 guidelines in development, rolling programme

XXX scoping

Full guideline takes XXX monthsOmani ‘evidence Omani ‘evidence

translation and utilisation’translation and utilisation’

Omani national audit Omani national audit providing ‘benchmarking providing ‘benchmarking

for quality’for quality’

Omani ‘healthcare system Omani ‘healthcare system change leading to change leading to

sustainable improvements’sustainable improvements’

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Henry Ford

• Coming together is a beginning

• Keeping together is progress

• Working together is success