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Agency for Quality in Medicine (AQuMed). Joint Institution of the GMA and NASHIP. Guidelines in Germany C. Thomeczek 2nd ENQual workshop Helsinki, 2./3. April 2004. The German CPG Story Part 1: ASMS CPG-Programme.

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slide1

Agency for

Quality in Medicine

(AQuMed)

Joint Institution

of the GMA

and NASHIP

Guidelines in Germany

C. Thomeczek

2nd ENQual workshop

Helsinki, 2./3. April 2004

www.azq.de

the german cpg story part 1 asms cpg programme
The German CPG StoryPart 1: ASMS CPG-Programme

1994 The High Advisory Council for the Concerted Action in Health Care recommends CPGs to be developed by the Scientific Medical Societies

1995 The Association of the Scientific Medical Societies (ASMS) inaugurates its CPG programme

12/97 320 National ASMS CPGs are available via WWW

3/99 718 CPGs via WWW

10/99 988 CPGs via WWW

www.azq.de

key problems of the asms cpg programme
Key Problems of the ASMS CPG Programme

1. less than 10 % of ASMS-CPGs mention recommendations' evidences

2. most of them contain no information regarding the CPGs‘

development process

sponsorship / accounbtability

implementation

3. cost-benefit-questions are explicitly excluded as topic from the ASMS programme

4. Differing guidelines on relevant topics

www.azq.de

the german cpg story part 2 gma naship cpg quality programme 1
The German CPG Story – Part 2: GMA/NASHIP CPG-Quality Programme (1)

4-10/96 Development of the German Guideline for CPGs

2-3/97 A plan of action for a German Guideline Clearinghouse (GGC) is recommended to GMA and NASHIP

4-12/97 Development of GGC-Tools

CPG Critical Appraisal Checklist

CPG Critical Appraisal Reports

GERGIS (German GCP Information WWW Service)

www.azq.de

the german cpg story part 2 gma naship cpg quality programme 2
The German CPG Story –Part 2: GMA/NASHIP CPG-Quality Programme (2)

1/98 GMA and NASHIP commission AQiM to operate the GGC

3/98 GERGIS is available via WWW

4/98 German Cochrane Centre and AQiM publish 1st CPG- Critical Appraisal Report (Asthma bronchiale)

5/98 GMA and NASHIP offers ASMS, German Hospital Federation (GHF), National Association of Statutory Sickness Funds (NASSF) partnership in the GGC

1/99 GHF and NASSF accept GGC partnership

6/98-

3/99 ASMS member societies ask for cooperation in GGC

1/02 Federal Pension Funds became Members in GGC

www.azq.de

combined actions of ggc
Combined Actions of GGC

Priorisation of national CPG programmes

Critical appraisal of CPGs

Quality promotion of CPGs

Implementing national CPGs via Quality Circles (“Peer Review Group”) of SHI Physicians

Evaluation of CPG programmes

Support of EB-patient information services

www.azq.de

slide7

Legal Regulations regarding CPG-Implementation

§§ 137 fSGB V (1.1.2000, rev. 1.1.2004)

  • Coordination Council (Joint Federal Council) advises the MoH regarding criteria for disease management programs (voluntarilly for patients)
  • Criteria have to recognise state of the art health care as well as evidence based guidelines….. (the best avaible evidence)

www.azq.de

slide8

National Program

for GuideLines

of the GMA

NPL- Background

  • initiated by the implementation of DMP in § 137 f SGB V GMA initiated a National Program for Guidelines (105. Physician Council 2002)
  • Contract between GMA, NASHIP, ASMS for joint execution of program (25.9.2003)

www.azq.de

slide9

Status quo in Germany (1.4.2004)

  • GGC operated by GMA, NASHIP, GHF, NASSF and FPF
  • NPL operated by GMA, NASHIP and ASMS
  • Federal Law Code (SGB) incoporates critical apraisal of CPG and recommandation for DMP

www.azq.de

implementation of evidence based information how to overcome barriers
Implementation of Evidence-based InformationHow to Overcome Barriers ?

Evidence-based Information

(Guidelines, HTA-Reports, Cochrane-Reports etc)

Knowledge

? ?? GAP

In- and Out-Patient Care,

Health Professionals, Patients,

Health Administration, Politicians

Practice

www.azq.de

G.Antes, German Cochrane Center 2002

barriers against use of guidelines 1 mandatory top down implement
Barriers against use of guidelines1. Mandatory top-down implement.
  • CPGs should …not simply be imposed on professionals by hospital management or third party payers.
  • That would result in a standardisation of care that leaves insufficient room to do justice to the needs of each individual patient.
  • Neither are guidelines a simple tool for allocating scarce resources at the population level.

Council of Europe ( 2001) DEVELOPING A METHOLOLOGY FOR DRAWING UP GUIDELINES ON BEST MEDICAL PRACTICES – WWW.COE.INT

www.azq.de

to overcome barriers against use of guidelines 1 participation of target groups in cpg develop
To overcome barriers against use of guidelines:1. Participation of target groups in CPG develop.

People involved in guideline development

  • credible organisation responsible for guideline development
  • target users involved in guideline development (‘ownership’)
  • balanced multidisciplinary guideline development group
  • patient involvement

Council of Europe ( 2001) DEVELOPING A METHOLOLOGY FOR DRAWING UP GUIDELINES ON BEST MEDICAL PRACTICES – WWW.COE.INT

Grol, Cluzeau, Burgers (2003 ) Br J Cancer

www.azq.de

barriers against use of guidelines 2 uncertainties regarding legal status of cpgs
Barriers against use of guidelines2. Uncertainties regarding legal status of CPGs
  • Since CPGs are not issued by legislative bodies,they are not legal rules.
  • However, they may have or acquire legal significance, for instance when they are incorporated into binding rules.
  • The courts will not automatically equate compliance with CPGs with good medical practice.
  • Mere deviation from a guideline is unlikely to be considered as negligent.

Council of Europe ( 2001) DEVELOPING A METHOLOLOGY FOR DRAWING UP GUIDELINES ON BEST MEDICAL PRACTICES – WWW.COE.INT

www.azq.de

to overcome barriers against use of guidelines 2 clarify legal conditions of guidelines
To overcome barriers against use of guidelines:2. Clarify legal conditions of guidelines
  • Both health professionals and patients need to be aware of the legal implications of adhering to or not following guidelines.
  • As the role of guidelines in legal proceedings differs from country to country, it is essential that guideline programmes clarify the legal conditions of implementing CPGs in general to their potential users.

Council of Europe ( 2001) DEVELOPING A METHOLOLOGY FOR DRAWING UP GUIDELINES ON BEST MEDICAL PRACTICES – WWW.COE.INT

www.azq.de

barriers against use of guidelines 3 lack of dissemination implement strategy
Barriers against use of guidelines3. Lack of dissemination / implement. strategy
  • Results from many controlled trials and systematic reviews show that efforts to implement guidelines are often not very successful.
  • At best, small to moderate improvements in the care process have been found, whereas the impact on patient outcomes has often not been studied or proved to be absent.
  • Issues of implementation are seldom addressed in the development of guidelines.

Grol, Cluzeau, Burgers (2003 ) Br J Cancer

www.azq.de

to overcome barriers against use of guidelines 3 user oriented effective implementation
To overcome barriers against use of guidelines:3. User-oriented, effective implementation
  • production of different formats of the guideline, including patient versions, and tools for applications
  • use of Internet
  • multiple implementation strategies
  • review criteria, indicators for assessing the use of guidelines

Council of Europe ( 2001) DEVELOPING A METHOLOLOGY FOR DRAWING UP GUIDELINES ON BEST MEDICAL PRACTICES – WWW.COE.INT

Grol, Cluzeau, Burgers (2003 ) Br J Cancer

www.azq.de

slide17

Guideline Implementation

Key Elements (1)

  • Guidelines must become an essential element in the undergraduate and clinical training of health care professionals as well as in the continuing professional development of health care teams.

www.azq.de

Council of Europe: Rec 13, 2001

slide18

Guideline Implementation

Key Elements (2)

  • Systematic approach to managing the quality of health care based upon CPGs is essential.
  • Use various dissemination and implementation strategies in combinations.
  • Consider professional, organisational, financial, regulatory incentives and disincentives.
  • Consider barriersand facilitators of CPG use at both national and local levels (tailored implementation).

www.azq.de

Council of Europe: Rec 13, 2001

effectiveness of implem interventions
Effectiveness of Implem.Interventions

Effectiveness Type

Little or No

  • Educational materials only
  • Educational lectures

Variable

  • Audit and feedback
  • Local opinion leaders
  • Local consensus process
  • Patient-mediated interventions

Effective

  • Educational outreach visits
  • Reminders
  • Interactive educat. meetings
  • Multifaceted interventions

www.azq.de

slide20

Factors for Success of CPGs

Effective Dissemination and Implementation

  • Fundingmust be considered. The source of support must be transparent.
  • CPGs should target multiple audiences (professionals, patients, and policy makers) and be available in suitable formats for different groups.
  • CPG clearinghouses facilitate the accessibility of CPGs.

www.azq.de

Council of Europe: Rec 13, 2001

slide21

"Modules" for CPG Implement. in Primary Care (Germ. Ass. PC Phys.)

  • Long version
  • Short version (leaflet / vademecum)
  • Doctor‘s Aid version
  • Patient version
  • Electronic decision support system

www.azq.de

slide22

Implementation Aid : Electronic –CPG-based Decision Support – f.e. PRODIGY –www.prodigy.nhs.uk -

www.azq.de

slide23

Implem. of evid. based health care:

National level (out- and in-hospital care ) Tool:

Disease Management Programmes

www.azq.de

German Guideline Clearinghouse 2002

slide24

Disease Management in Germany

Goal: Effective Chronic Illness Care

(Diabetes, CHD, Asthma, COLD, Breast Cancer)

  • Self-management support: to help patients / families cope with the challenges of living with and managing chronic illness.
  • Patient support:goes beyond patient education and information; it equips patients with skills in managing their conditions
  • Decision support to practitioners: includes the effective implementation of evidence-based guidelines
  • Delivery system: includes well-prepared teams able to efficiently coordinate tasks and utilize key clinical data
  • Clinical information system: collects information about important elements of care and makes that information available to health care team members.

www.azq.de

slide25

1 / 2000

Quality Improvement: Example Diabetes

Median

RR-Levels

Typ 2 Diabetes

2000-2001

(Saxony)

4 / 2001

www.azq.de

na izsledkih temelje e smernice

The multidisciplinary team:

  • Medicine
  • Nursing
  • Allied health professionals
  • Health service managers
  • Patients

Clinical practice guideline

Local knowledge about care needs, support services, etc.

Care pathway 1

Care pathway 2

Care pathway 3

Care pathway 4

Care pathway 5

Implem. of evid. based health care:

Local level (hospital) Tool: Guideline based care pathways

Na izsledkih temelječe smernice...
  • dileme
      • splošne opredelitve vs. konkretna navodila
      • zagotavljanje potrebnih virov
      • racionalizacija dela
  • oblikovanje lastne metodologije
      • izvirnost
      • temeljni koncept - prilagoditev obstoječih smernic

Patient’s journey of care

Zlatko Fras ( 2003 ) National Clinical Practice Guidelines Project in Slovenia, Europ. Conference „Information and Quality in Health Care“, Krakow, 9 April 2003

www.azq.de

slide27

Implem. of evid. based health care:

Regional level (outpatient care) - Tools:

Find the guidelines

Compare CPGs’ contents

Look at the gaps

Do peer review

Appraise

quality

Analyze applicability

Look at the sources

Develop

Recommendations

Topic

Priori-

tisation

Regional guidelines based on national CPGs

+

CPD in „Quality Circles“

+

www.azq.de

slide28

Pharmacotherapeutic Circles

Guideline group

moderators

Pharmacotherapeutic Circles

data

Sickness Funds‘ Prescription Data Base

www.azq.de

slide29

Implem. of regional guidelines via quality circles:

Results – State of Hesse

  • PTC GPs deceased their costs by 2%, whereas drug costs for all physicians in Hessen rose about 10 %
  • Combination of education, current feedback mechanisms and printed media seems to be an effective method to optimise quality of care
  • easy adoption of the guidelines

Topics:

Diabetes, CHD, Hypertension, Astma, COLD, Dyspepsia / Ulcus

www.azq.de

slide30

Factors for Success of CPG Implementation

Evaluation of Guidelines’ Impact

  • Well-planned monitoring of guideline effects is essential, and especially the impact of guidelines on health outcomes needs further development and evaluation.
  • Guidelines can include a list of essential indicators that can be used for evaluating the results of guideline implementation.

www.azq.de

Council of Europe: Rec 13, 2001