TEACH: LEVEL II – CLINICAL POLICIES AND GUIDELINES STREAM

TEACH Plenary

NYAM

August 8th, 2012

Craig A Umscheid, MD, MSCE, FACP

Assistant Professor of Medicine and Epidemiology

Director, Center for Evidence-based Practice

Medical Director, Clinical Decision Support

University of Pennsylvania

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Goal

To gain knowledge, attitudes and skills required to develop and adapt clinical policies and guidelines for implementation in specific health care settings.

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Faculty

Karen Schoelles, MD, MS• Director, AHRQ EPC, ECRI Institute, Plymouth Meeting, PA

Jonathan Treadwell, PhD• Associate Director, AHRQ EPC, ECRI Institute, Plymouth Meeting, PA

Louise Falzon, MSLS• Cochrane and Columbia University, NY, NY.

Ian Graham, PhD• Vice-President, Knowledge Translation and Public Outreach Portfolio,

Canadian Institutes of Health Research.

Richard Rosenfeld, MD, MPH• Professor and Chairman, Otolaryngology, SUNY Downstate, Editor-in-

Chief, Otolaryngology – Head and Neck Surgery, President, American Society of Pediatric Otolaryngology

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Objectives

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Objectives (continued)

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Daily Schedule

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An Illustrative Case: Surgical Site Infections

You’re the Chair of the Department of Surgery Quality Committee at your medical center, and you receive a call from your Chief Medical Officer regarding a report that your state just released about SSI rates at medical centers across the state. It’s not good news. Your medical center had the highest rate of SSIs in the state.

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Using evidence to define the problem

Does it warrant attention? Is it a misperception?

Local evidence• Anecdote vs. data• Compare over time, across units, across institutions• Structure, process, outcome

Peer-reviewed evidence• National estimates• Compare local practices to national recommendations• Potential causes and solutions identified in published studies

Mitchell MD, et al. Integrating local data into hospital-based healthcare technology assessment: two case studies. Int J Technol Assess Health Care. 2010;26(3):294-300.

Lavis JN, et al. Using research evidence to clarify a problem. Health Research Policy and Systems. 2009, 7(Suppl 1):S4 doi:10.1186/1478-4505-7-S1-S4.

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Building a team to define and address the problem

Key stakeholders

Multidisciplinary

Champions

Executive leadership (credibility, resources, influence)

Conflicts of interest

Consumer Participation In Evaluation (PIE) Matrix

Harris C, Turner T and Wilkinson F. Guideline Development Toolkit. (2008) The Centre for Clinical Effectiveness, Southern Health, Melbourne, Australia.

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Framing options to address the problem

Frame or “fit” problem within priorities of leadership to motivate support and solutions

Lavis JN. Using research evidence to clarify a problem. Health Research Policy and Systems. 2009, 7(Suppl 1):S4 doi:10.1186/1478-4505-7-S1-S4

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PICO and Analytic Frameworks

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Daily Schedule

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Pyramid: 3 dimensional “3-S” model linking study designs to electronic resources

Silva SA, Wyer PC. The Roadmap: a blueprint for evidence literacy within a Scientifically Informed Medical Practice and Learning (SIMPLE) model. The International Journal of Person Centered Medicine. 2012. (In press)

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National Guideline Clearinghouse

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PubMed: Guidelines and Reviews

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Cochrane Library: Reviews and HTAD

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Daily Schedule

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Trustworthy Guidelines

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IOM

IOM domains

1. Establishing transparency

2. Management of conflict of interest

3. Guideline development group composition

4. Clinical practice guideline - systematic review intersection

5. Establishing evidence foundations for and rating strength of recommendations

6. Articulation of recommendations

7. External review

8. Updating

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AGREE II Instrument

Tool to assess the quality of clinical practice guidelines.

Composed of 23 items in 6 domains:• Scope and purpose (3 items)• Stakeholder involvement (3 items)• Rigor of development (8 items)• Clarity of presentation (3 items)• Applicability (4 items)• Editorial independence (2 items)

Two Overall Assessments:• Rating of the overall quality of the guideline• Whether the user recommends the guideline for use in practice

AGREE II: Advancing guideline development, reporting and evaluation in health care. Brouwers et al., Journal of Clinical Epidemiology 63 (2010) 1308e1311

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Daily Schedule

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Hospital-based Health Tech Assessment

J Gen Intern Med. 2010; 25(12):1352–5

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Daily Schedule

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Daily Schedule

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CAN-IMPLEMENT©: a six step model

Tool 2.3a Skills Assessment Checklist

Tool 4.1o Recommendations Matrix (template)

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Daily Schedule

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Daily Schedule