Getting a Grip on Guidelines. A public lecture on the Science & Art of Implementing Evidence. Dave Davis, MD, CCFP, FCFP, FRCPC (hon) University of Toronto Faculty of Medicine Associate Dean, Continuing Education Principal Investigator, Knowledge Translation Program
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Dave Davis, MD, CCFP, FCFP, FRCPC (hon)
University of Toronto Faculty of Medicine
Associate Dean, Continuing Education
Principal Investigator, Knowledge Translation Program
Ontario Guidelines Advisory Committee, Chair
Ideal, evidence-based practice
clinical care gap
Identify a clinical gap in practice/health care with which you’re familiar
Acute Otitis Media
65-80% vs 20%
?Mammography for low risk women age 40-50
(Ministry of Health, Ontario data, 2001-04):
Modified radical mastectomy in breast CA
Routine, pre-op chest X-rays, EKGs
Lumbosacral X-rays for acute low back pain
*Routine q6-12month echocardiograms in stable CHF
*? Sleep studiesoveruse
Pap Smears: Pirkis, 1998
CHF & ACE inhibitors Hickling 2001
and beta blockers in the elderly; McAlister 1999
Post MI patients
Lipid lowering: Kong, 1998; Aronow, 1998
Atrial Fib & anticoagulation
Diagnosis of mental disorders
Craig and Boardman, 1997
?Screening for colorectal cancer >50
Beta blockers in diabetics, asthmatics
Tricyclic antidepressants in the presence of cardiac arrhythmias
Cisapride (knowing what we know today)Underuse
Describe the causes of the gap
The educational delivery
emphasis on knowledge, not knowledge management
inability to detect needs, evaluate performance
type of practice
too narrow a definition of ‘learner’
learning cycle: awareness, agreement, adoption, adherenceproblems with the learner-clinician
No, Thursday’s out. How about never-is never good for you?
“Information managementis like having your mouth to a firehose” David Naylor, Dean, Faculty of Medicine, University of Toronto
“It’s pretty simple, really: just review the world literature every two weeks”
Sharon Straus, KT program,
University of Toronto
(not the guy in CLUE)
Dean, Faculty of Health Sciences, McMaster University
Randomized Controlled Trials
Replicable, educational interventions: meetings, feedback, audiotapes, reminders, lectures, etc
>50% practicing physicians/professionals
Objective outcomes of physician performance or patient/health care status
Formal educational meetings
Local opinion leaders
Patient mediated strategies
AMA, ACME, SACME, Royal College of Physicians and Surgeons of Canada, the University of Toronto
very narrow, quantitative, EBM-ish RCT bias
focus of this review - change, not learning
nature of field
What we do doesn’t work
What we don’t do doesSome comments on these reviews….
What are the implications of this gap, and its causes, for us as practitioners?
The AGREE instrument –
The Not-all-guidelines-are-equal Guideline
CLARITY and PRESENTATION
RIGOR OF DEVELOPMENT
SCOPE and PURPOSE
2. Stakeholder involvement
focuses on the extent to which the guideline represents the views of its intended users.
Item 4. The guideline development group includes individuals from all relevantprofessional groups
Item 5. The patients’ views and preferences have been sought
Item 6. The target users of the guideline are clearly defined.
Item 7. The guideline has been piloted among target users.
3. Rigor of development
relates to the process used to gather and synthesize the evidence, the methods to formulate the recommendations and to update them.
Item 8. Systematic methods were used to search for evidence
Item 9. The criteria for selecting the evidence are clearly described
Item 10. The methods used for formulating the recommendations are clearly described
3. Rigor of development (continued)
Item 11. The health benefits, side effects, and risks have been considered in formulatingthe recommendations
Item 12. There is an explicit link between the recommendations and the supporting evidence
Item 13. The guideline has been externally reviewed by experts prior to its publication
Item 14. A procedure for updating the guideline is provided
deals with the language and format of the guideline.
Item 15. The recommendations are specific and unambiguous
Item 16. The different options for management of the condition are clearly presented
Item 17. The key recommendations are easily identifiable
Item 18. The guideline is supported with tools for application
pertains to the likely organizational, behavioral and cost implications of applying the guideline.
Item 19. The potential organisational barriers in applying the recommendations havebeen discussed.
Item 20. The possible cost implications of applying the recommendations havebeen considered
Item 21. The guideline presents key review criteria for monitoring and/or audit purposes
concerned with the independence of the recommendations and acknowledgement of possible conflict of interest from the guideline development group.
Item 22. The guideline is editorially independent from the funding body
Item 23. Conflicts of interest of guideline development members have been recorded
The clinical care gap: possible theory-to-practice solutions, probable research questions
Ideal, evidence-based practice
knowledge translation strategies
Methods/ Stages solutions, probable research questions
- Print material,
- Academic detailing - Media campaigns
- Opinion leaders
- Pt. Education,
- Opinion leaders
2) Solving the ‘CME’/Intervention Problem – a possible modelBMJ 2003
Solving the learner problem #3: solutions, probable research questionsConsumers can drive change, too: why not educate them?
NHS Consumer Health Information Web Site December 2001 5.2 million hits – 171,900 visitors (Powell & Clarke, 2002)
Fifty-eight per cent of GPs have been approached by patients with Internet healthcare information. Sixty-five per cent of the information presented by patients was new to GPs. (Wilson, 1999)
NOTE: communication skills
For more information……. solutions, probable research questions