From Evidence to EMS From Evidence to EMS Practice: Building the Practice: Building the National ModelNational Model

Eddy Lang, MD, CFPC (EM), CSPQ

SMBD-Jewish General Hospital,

McGill University

Montreal, Canada

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Overview

Research evidence versus consensus/expert based CPGs

Avoiding GOBSAT methodology Unique EMS aspects to consider A broader perspective about CPGs Other aspects that can influence this CPG

project

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Clinical practice guidelines

Systematically developed statements or recommendations to assist practitioner about appropriate health care for specific clinical circumstances.

Institute of Medicine (1992). Guidelines for clinical practice: from development to use.

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The promise of guidelines

Evidence Synthesis Reduced variation in care Guidance Improved patient outcomes Improved system efficiency Benchmarks

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The pitfalls of guidelines

Biased Overwhelming Confusing Directionless Driven only by evidence Not implemented

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Evidence Mastery

Primary Domains of CPG Development

Options Questions Search Selection Appraisal Strength of evidence Combining studies Effect size

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Evidence Mastery

ContextRisk/benefits

Values Preferences

Primary Domains of CPG Development

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Graded Recommendations

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Graded Recommendations

Valid Reliable Clear

Implementable

Transparent UnbiasedCredible

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What makes a great CPG?

What domains are important? What criteria within each domain? Can a rigorously developed appraisal tool

inform?

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Appraisal of Guidelines for Research and Evaluation

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AGREE instrument Generic tool designed primarily to help

guideline developers Developed by international collaborative

group including 16 partners from 12 countries (including Canada, New Zealand, US)

Reliability and some aspects of validity assessed

Users guide available Translated into most European languages

(including French)

AGREE STRUCTURE

Six domains – 23 itemsSix domains – 23 items

1. Scope & purpose (3)

2. Stakeholder involvement (4)

3. Rigour of development (7)

4. Clarity & presentation (4)

5. Applicability (3)

6. Editorial independence (2)

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DOMAIN 1.SCOPE AND PURPOSE

1. The overall objective(s) of the guideline is(are) specifically described.

2. The clinical question(s) covered by the guideline is(are) specifically described.

3. The patients to whom the guideline is meant to apply are specifically described.

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DOMAIN 2.STAKEHOLDER INVOLVEMENT4. The guideline development group

includes individuals from all the relevant professional groups.

5. The patients’ views and preferences have been sought.

6. The target users of the guideline are clearly defined.

7. The guideline has been piloted among target users.

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DOMAIN 3.RIGOUR OF DEVELOPMENT (1) 8. Systematic methods were used to

search for evidence.

9. The criteria for selecting the evidence are clearly described.

10. The methods used for formulating the recommendations are clearly described.

11. The health benefits, side effects and risks have been considered in formulating the recommendations.

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DOMAIN 3.RIGOUR OF DEVELOPMENT (2)

12. There is an explicit link between the recommendations and the supporting evidence.

13. The guideline has been externally reviewed by an expert panel prior to publication.

14. A procedure for updating the guideline is provided.

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DOMAIN 4.CLARITY AND PRESENTATION

15. The recommendations are specific and unambiguous.

16. The different options for management of the condition are clearly presented.

17. Key recommendations are easily identifiable.

18. The guideline is supported with tools for application.

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DOMAIN 5.APPLICABILITY19. The potential organisational barriers

in applying the guideline have been discussed.

20. The potential costs implications of applying the recommendations have been considered.

21. The guideline presents key review criteria for monitoring and/or audit purposes.

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DOMAIN 6.EDITORIAL INDEPENDENCE

22. The guideline is editorially independent from the funding body.

23. Conflicts of interest of guideline development members have been recorded.

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A Whirlwind Tour of the CPG World

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Guideline International Network

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ADAPTE

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Very few EMS-specific CPGs

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Many existing CPGs address EMS

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Grading of Recommendations Assessment, Development and Evaluation

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Closing thoughts

Exciting times in CPG development Much accumulated wisdom Many challenges to meet Unprecedented opportunity to

improve EMS patient care

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