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European Best Practice Guidelines. James Tattersall. Background. Process commissioned by EDTA-ERA in 1998 KDOQI, CARI, UK renal guidelines already published Considerable guideline activity underway “Expert groups” Transplant (2000, 2002) HD (2002, 2007) PD (2005) Anaemia (1999, 2005).

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background
Background
  • Process commissioned by EDTA-ERA in 1998
    • KDOQI, CARI, UK renal guidelines already published
    • Considerable guideline activity underway
  • “Expert groups”
    • Transplant (2000, 2002)
    • HD (2002, 2007)
    • PD (2005)
    • Anaemia (1999, 2005)
co operative initiatives
Co-operative initiatives
  • K/DOQI
    • Bone metabolism 2004
    • Hypertension in CKD 2004
    • CVD in dialysis 2005
    • Anemia 2006
  • KDIGO
    • Classification/ definition CKD
    • Hep C
    • Bone/mineral metabolism
organisation facilitating guidelines
Organisation facilitating guidelines
  • Logistical and secretarial
    • Baxter
    • Fresenius
    • Hoffman-La Roche, Amgen, Vifor, Ortho-Biotech
  • Literature search and evidence grading
    • Cochrane (HD)
    • Thomson Gardiner-Caldwell (Anaemia)
  • Collection of feedback and dissemination of guidelines
    • EDTA-ERA
funding sources
Funding sources
  • Baxter (PD)
  • Fresenius (HD)
  • Hoffman-La Roche (Transplant, Anaemia)
  • Amgen (Anaemia)
  • Ortho Biotech (anaemia)
  • Vifor (anaemia)
how guidelines relate to healthcare systems in area
How guidelines relate to healthcare systems in area
  • Europe is diverse
    • 30 + countries
    • Mixture of models (socialised, insurance-based)
    • Mixture of languages.
    • Differences between levels in healthcare funding.
    • ‘New’ ex-soviet empire European countries inherited broken systems.
  • At least for dialysis, convergence was surprisingly rapid.
  • No attempt to include cost-benefit in the guidelines
selection and prioritisation of guideline topics
Selection and prioritisation of guideline topics
  • No formal process
  • Decided by the expert groups (HD, PD, Transplant)
    • Composition of group
    • Existing guidelines
    • Availability of evidence
    • Considered to be important
selection of expert groups
Selection of expert groups
  • Invited by the ERA-EDTA council.
  • No formal selection process
  • European experts on the guideline topic
    • No more than 1-2 per country in each group.
  • Initially only nephrologists
    • HD group invited one dietician, one radiologist and one surgeon for 2nd part.
methodology
Methodology
  • Delegated to expert groups.
  • Division into sub-groups (3-4 members)
  • Formulation of important questions
  • Generation of key words
  • Literature search performed by Cochrane
  • All literature graded by Cochrane
  • All literature scored by expert group.
    • Each paper scored by at least 2 members.
    • Modified READER system (with elements of GRADE) used to score papers.
methodology 2
Methodology (2)
  • Randomly selected papers presented to group and the scores challenged by whole group.
  • Low-scoring papers automatically rejected
    • Reader score includes relevancy.
  • Rejected papers retained as part of the guideline audit.
  • Guidelines formulated by sub-groups.
  • Guidelines presented and circulated to entire group.
  • All guidelines signed-off by each group member.
methodology 3
Methodology (3)
  • External expert reviewers selected
    • Non-nephrologists
    • Non-European
  • Draft guidelines submitted to
    • Reviewers
    • ERA-EDTA membership
    • Selected international nephrology societies (ISN, ASN, CSN, CARI)
    • All European national associations.
disseminations and implementation
Disseminations and implementation
  • Draft guidelines, responses and proposed amendments presented at ERA-EDTA conference 2006
  • Final versions published 2007
    • Published in NDT
    • ERA-EDTA website
  • Impact to be assessed by QUEST projects.
    • Adequacy of HD
strengths
strengths
  • Formal, independent selection of evidence.
  • Formal, transparent scoring of papers.
  • Consultation at late stages
  • Ongoing study to assess impact (QUEST)

weaknesses

  • Commercial funding
  • Qualification/selection of expert groups.
  • No patient, manager or nurse representation.
  • Inconsistent style, format, terminology
  • No consideration of guideline lifecycle
  • No consultation at early stage
    • Prioritisation
    • Questions asked
    • What the guidelines are trying to achieve not clearly stated.
future outlook
Future outlook
  • ERA-EDTA have a responsibility to maintain, update, withdraw or correct existing guidelines.
  • Impact of existing guidelines to be monitored by QUEST
  • ERA-EDTA council have decided that the Association should remain involved in new guideline development.
  • The form of this involvement has not yet been decided.
  • First EBPG meeting January 2008