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Knowledge (evidence) translation and utilisation, leading to improved patient outcome. ‘A whole healthcare systems approach’. NCGC. Commissioned by DH & NICE 20+ guidelines / QS in development Budget of £4.56 million (2,818,008 OMR) ~70 staff – specialist expertise EMB
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Knowledge (evidence) translation and utilisation, leading to improved patient outcome ‘A whole healthcare systems approach’ Ian Bullock Jill Parnham
NCGC • Commissioned by DH & NICE • 20+ guidelines / QS in development • Budget of £4.56 million (2,818,008 OMR) • ~70 staff – specialist expertise EMB • Inter related work with RCP Clinical Standards
NCGC UK STAKEHOLDERS context Patients Professions NHS Industry
NCGC Vision that is: • Focussed on quality (Quality Standards) • Patient centred (High political priority) • Clinically driven (Professionally important) • Flexible (Diverse work programme) • About valuing people (Always about people) • Promoting continuous improvement(With growth inevitably comes increased responsibility)
The quality spiral • Largest EB guideline centre in world • Commissioned by DH / NICE • 14 guidelines in development, rolling programme • XXX scoping • Full guideline takes XXX months
National Clinical Guideline Centre • Formed on April 1st 2009 • Merger of 4 National Collaborating Centres - Primary Care (RCGP) - Chronic Conditions (RCP) - Nursing and Supportive Care (RCN) - Acute Conditions (RCS) • Hosted by Royal College of Physicians
Guideline Development • Multidisciplinary group • Supported by technical team (researchers; health economists; information scientists and project managers) • Technical team are members of the group with voting rights
Developing clinical guidelines • Scoping: Identify and refine the subject area • Convene multi disciplinary guideline development groups including patients/carers • Develop clinical questions: process started • Obtain and assess the evidence about the clinical questions • Analyse and present evidence to GDG • Translate the evidence into recommendations (clinical guideline) • Arrange external review of the guideline
Mark Twain • ‘Synergy — the bonus that is achieved when things work together harmoniously.’
Answering the clinical questions • Each recommendation needs to relate to a question • Each question has to be addressed with a systematic review of the evidence • Each systematic review requires • A question protocol listing inclusion/exclusion criteria • A comprehensive literature search • Each study reviewed to be quality assessed using NICE forms* • Each included study to have data extracted into an evidence table • Each outcome from each question to be synthesised into a meta-analysis (where possible)* • The collated estimate for each outcome to be assessed using GRADE* • Results written up in the guideline
Types of questions • Aetiology/causation • Diagnosis/screening • Prognosis • Effectiveness (therapy, clinician, organisation) • Cost-effectiveness • Harm • Variation in practice • Equity • Experience and meaning
General structure of a clinical question • The acknowledged structure is known as PICO • Population • Intervention (or exposure for prognosis) • Comparison (optional) • Outcome
NICE principles – include social value judgements • Need evidence to recommend an intervention (can make ‘research only’ recommendations) • Clinical and cost effectiveness • Good use of resources • Can make recommendation for a subgroup of population if clear evidence for effectiveness • Involve and respond to stakeholders • Equalities • Transparency
How evidence presented to GDG • Details of study – where, population groups, interventions etc • Quality assessment – checklists/GRADE • Results – varies e.g. narrative, forest plots • Interventions – GRADE profiled • Meta-analysis where possible • Health economic modelling outcomes ‘evidence’
Why consider cost-effectiveness? • The NHS does not have enough resources to do everything • If it spends more on one thing, it has to do less of something else • Could we do more good by spending money differently? • Prioritise interventions with a high health gain per £ spent
Why are recommendations difficult in evidence based guidelines? • No evidence • Poor evidence • Doesn’t answer the question • Wrong patient group • Wrong comparator • Wrong outcome
Options when evidence poor/no evidence • Extrapolate if possible (indirect evidence) • Expert group discussion (informal consensus) • Vote • Formal consensus decision making • Transparency and acknowledgement • No recommendation
NICE (NCGC) and Quality Initiatives • 2000 -2006 • Focus on guidance, not indicators or standards • Clinical Guidelines; Public Health Guidance and Technology Appraisals • Developed audit tools directly based on NICE guidelines • 2008 • Labour Government’s Next Stage Review • Expanded role for NICE in Quality Indicator Development • NICE-managed QOF for general practice • NICE to develop Quality Standards • 2010 (July) • Coalition Government’s Health White Paper • NHS Outcomes Framework • NICE Quality Standards seen as central to delivering this
What are Quality Standards? • Quality statements • Descriptive statements (5 to 10) of the critical infra-structural and clinical requirements for high quality care as well as the desirable/expected outcomes • Key points on care pathway • Quality measures • Structure, process (and outcome) measures • “High Level” Quality Indicators • Use at local level as audit criteria • Inform subsequent national indicator development
What are Quality Standards? • Audience descriptors • A description of what the quality standards mean for different audiences • Service providers • Health and Social Care Professionals • Commissioners • Patients
What is the purpose of Quality Standards? • To make it clear what high quality care is by providing definitions of clinical and cost-effective care • To support benchmarking of performance • To provide information to patients and the public about the quality of care they can expect
NICE Quality Standards programme • Aims • To develop Quality Standards for topics selected by the National Quality Board (NQB)/ NHS Commissioning Board on an annual basis • To offer clarity about what high quality care looks like across 3 dimensions of quality ensuring: • Patient care is effective • Patient care considers patient experience • Patient care is safe • To develop a comprehensive set • 150 to be developed over 5 years
Current Work Programme NCGC produced
Evidence Source • Policy Drivers • Audit evidence on current care Quality Standard NICE quality standards • NICE quality standard • Quality statements • Measures Clinical Guideline Recommendations - NHS Evidence Accredited Sources • Key Department of Health and other documents • National Clinical Audits • - Current clinical practice (areas requiring improvement)
NICE Stroke Quality Standard • Scope of Quality Standard: • Care provided to adult stroke patients • diagnosis and initial management, acute phase care, rehabilitation and long-term management • Policy context: • Department of Health “National Stroke Strategy” (2007) • Department of Health “Reducing Brain Damage: faster access to better stroke care” (2005) • Key development sources: • Royal College of Physicians “National Clinical Guideline for Stroke” (2008) which incorporates NICE CG68 Diagnosis and initial management of acute stroke and transient ischaemic attack (2008) • National Sentinel Audit for Stroke (2000 – ongoing)
Example quality statement for stroke • In a high quality service for patients with stroke ... • Patients with acute stroke receive brain imaging within 1 hour of admission if they meet any of the indications for immediate imaging (QS2) • Relevant CG recommendation • Brain imaging should be performed immediately (within 1 hour) for people with acute stroke if any of the following apply …
Example of quality measure for stroke • Structure:Evidence of local arrangements to ensure patients with acute stroke receive brain imaging within 1 hour of arrival at the hospital if they meet any of the indications for immediate imaging. • Process: Proportion of patients with acute stroke who meet any of the indications for immediate imaging who have had brain imaging within 1 hour of arrival at the hospital. [Numerator & Denominator defined]
What the quality statement means for each audience – stroke example • Service providers ensure facilities and protocols are available for patients to receive brain imaging within 1 hour of arrival at the hospital if they meet any of the indications for immediate imaging. • Health care professionalsensure that patients under their care with acute stroke receive brain imaging within 1 hour of arrival at the hospital if the criteria for immediate imaging are met. • Commissionersensure that services they commission enable patients to receive brain imaging within 1 hour of arrival at the hospital if they meet any of the indications for immediate imaging. • Patientswith acute stroke with any of the indications for immediate brain imaging can expect to receive this within 1 hour of arrival at the hospital.
Data Source • Structure:Local data collection. • Process:Trusts can collect data via the Sentinel Stroke Audit, Hospital Episode Statistics (HES) data and through local data collection. • There exist existing quality assured indicators • Sentinel Stroke Audit CV02 • Proportion of stroke patients given a brain scan within 24 hours of stroke • DH WCC Assurance Framework Acute 36 • Percentage of stroke admissions given a brain scan within 24 hours
How will quality standards be used? Used to drive up the quality of health care • For use by: • patients, the public, health and social care professionals, commissioners and service providers • Can be used in: • commissioning, payment mechanisms and incentives schemes such as CQUIN, Quality Accounts and Care Quality Commission special reviews
Stroke quality spiral • Epidemiology • Policy context • Setting standards • Measuring standards • Improving quality of clinical care
Stroke • Stroke is one of the top three causes of death and the largest cause of adult disability in England, and costs the NHS over £3 billion (1,854,274,200 OMR) a year.
Stroke • In 2008-09, the direct care cost of stroke was at least £3 billion annually, within a wider economic cost of about £8 billion (4,945,200,233 OMR). • Without preventative action, there is likely to be an increase in strokes as the population ages.
Stroke • One in four people who have a stroke die of it. • There are approximately 110,000 strokes and 20,000 TIAs per year in England. • 300,000 people are living with moderate to severe disabilities as a result of stroke.
NICE Acute Stroke Guideline • Took 24 months to develop • 18 experts plus technical team • Rigorous and systematic methodology • Published 2008 • Looked at thousands published papers • Based recommendations upon 200 key papers • Made 62 EB recommendations
Stroke care pathway • ‘Time lost is brain lost’ • Pathway derived from the evidence based NICE guideline
Guidelines • The NICE guideline (July 2008) covers interventions in the acute stage of a stroke (‘acute stroke’) or transient ischaemic attack (TIA). • Most of the evidence considered relates to interventions in the first 48 hours after onset of symptoms, although some interventions up to 2 weeks are covered.