Clinical Guidelines

1. Dr Aravinda B Sathish GP ST1 19TH JAN 2010 Clinical Guidelines

2. What’s in the presentation • Introduction • Potential benefits • Limitations and harms • Developing clinical guideline • Guidelines in practice • Conclusion

3. What are clinical guidelines? • "Systematically developed statements toassist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances." --------------------Defined by the Institute of Medicine • Help health professionals and patients make the best decisions.

4. Who writes clinical guidelines for the UK? • The main organisations in the UK involved in writing and publishing guidelines include: • NICE- National Institute for Health and Clinical Excellence • SIGN - Scottish Intercollegiate Guidelines Network • GAIN - Guidelines and Audit Implementation Network • CKS - Clinical Knowledge Summaries (formerly Prodigy) • Professional Organisations and Royal Colleges

5. Guidelines from around the world Sources of clinical guidelines written outside the UK include: • National Guideline Clearinghouse - a US directory of evidence-based clinical practice guidelines. • New Zealand Guidelines Group - an independent society providing evidence-based technical assistance and clinical guidelines to healthcare organisations, government departments, etc. • The Guidelines International Network- an international not-for-profit association of organisations and individuals involved in clinical practice guidelines.

6. Potential benefits, limitations, and harms of clinical guidelines BMJ 1999; 318:527-530 (20 February) BENEFITS—To Patients • improve health outcomes • improve theconsistency of care • patients will be cared for in the same manner regardlessof where or by whom they are treated. • empower patients to make more informed healthcare choicesand to consider best option. • clinical guidelines can help patients by influencing public policy.

7. For healthcare professionals • improve the qualityof clinical decisions • reinforce the importance & methods of criticalappraisal • support quality improvement activities. • common pointof reference for prospective and retrospective audits of clinicians or hospitals practices. • Essential for medicolegal protection and to reinforce practicepolicies. • Effective in improvingefficiency (by standardising care) and optimising valuefor money. • Improve public image,can promote good will, political support, and (in somehealthcare systems) revenue

8. Potential limitations of guidelines To Patients • Most important limitation-----recommendations may be wrong (or at least wrong forindividual patients). • Scientific evidence may be lacking, misleading, or misinterpreted • Recommendations influenced by opinions and clinical experience. • Patient’s needs may not be considered in making recommendations. • Potentially harmful to patients if due account of evidence is not taken into consideration and can result in suboptimal, ineffective, or harmfulpractices. • May be misleading or confuse patients and disrupt the doctor-patientrelationship.

9. To healthcare professionals • By providing inaccurate scientific information and clinical advice, compromise the quality of care • Encourage ineffective,harmful, or wasteful interventions. • Conflicting guidelines can confuse and frustrate practitioners • Guidelines can harm medical investigators and scientific progress if further research is discouraged.

10. Potential harms to healthcare systems • Can escalate utilisation & compromiseoperating efficiency. • may advocate costly interventionsthat are unaffordable or cut into resources needed for moreeffectiveservices.

11. Developing guidelines BMJ 1999;318:593-596 ( 27 February ) Skills needed for guideline development • Literature searching and retrieval • Epidemiology • Biostatistics • Health services research • Clinical expertise • Group processing expertise • Writing and editing

12. Steps in developing a Guideline • Identifying and refining the subject area is the first step in developing a guideline   • Convening and running guideline development groups is the next step • Setting up a guideline development project • Group membership and roles-group leader, specialist resource,technical support, and administrative support. • On the basis of systematic reviews, the group assesses the evidence about the clinical question or condition collect all available evidence, assess its potential applicabilityto the clinical question, inspect the evidencefor susceptibility to bias, extract and summarise thefindings.

13. Steps in developing a GuidelineThis evidence is then translated into a recommendation within a clinical practice guidelineFactors contributing to the process of deriving recommendations • The nature of the evidence (for example, its susceptibility to bias) • The applicability of the evidence to the population of interest (its generalisability) • Costs • Knowledge of the healthcare system • Beliefs and values of the panel

14. Steps in developing a Guideline • The last step in guideline development is external review of the guideline/Updating • Ext review by-----people with expertise in clinical content, expertsin systematic reviews or guideline development potentialusers of the guideline. • In Britain__ a further review process---guidelines are appraisedby an independent unit to assess whether the NHS Executive cancommend them to theNHS. • The guideline can be updated as soon as each piece of relevant new evidence is published, but it is better to specify a datefor updating the systematic review that underpins theguideline.

15. Where to look for the guidelines? • The National Library of Guidelines • NHS Evidence • NICE - National Institute for Health and Clinical Excellence • SIGN - Scottish Intercollegiate Guidelines Network • GAIN - Guidelines and Audit Implementation Network • CKS - Clinical Knowledge Summaries (formerly Prodigy) • Professional Organisations and Royal Colleges

16. The National Library of Guidelines Database of UK approved ---evidence-based clinical guidelines available on the internet in full-text, and associated information. Maintained by the University of Sheffield Health Science Library in partnership with NHS Evidence Key Aspects of the National Library of Guidelines • Comprehensive index to UK national clinical guidelines. • All Guidelines listed are available in full-text. • Searchable by keyword in the title or abstract, or browsable by Specialty. • All Guidelines have an abstract. • News and events relevant to those working with Guidelines will be posted. • Select bibliographies provided on guideline development and guideline appraisal. • The guidelinesare available in English Language. • The guidelinesare available on the Internet and freely available to the public or to NHS registered Athens users.

17. NHS Evidence • Provided by NICE, NHS Evidence is a new service which will develop, enhance and expand the services that were previously provided by the National Library for Health (NLH). • Background • NHS Evidence allows everyone working in health and social care to access a wide range of health information to help them deliver quality patient care. Launched in April 2009, NHS Evidence: • has a fast, free and easy to use search engine to help users search for the • information they want • ranks search results from credible medical sources according to relevance and • quality • allows users – through My Evidence - to personalize a search and register to • receive the latest health information • awards an Accreditation Mark to organisationswho meet high quality standards in • developing health information

18. What's on NHS Evidence NHS Evidence provides free access to clinical and non-clinical information - local, regional, national and international. Information includes evidence, guidance and Government policy. NHS staff who have an Athens account can also get free access to paid for journals. Who is NHS Evidence for? NHS Evidence is for everyone in health and social care who takes decisions about treatments or the use of resources including: • GPs and nurses • Consultants • Commissioners and service managers • Allied health professionals • Pharmacists • Public Health teams • Librarians

19. NHS Evidence provides access to 34 specialist collections which cover a wide range of common medical conditions, topics and health populations, and which were formerly part of the National Library for Health. • NHS Evidence is as easy to use as other popular search engines • The service provides a simple search of many sources of clinical, non-clinical and social care information. • The search can be freely accessed without the need for logging in, and the full text of the search results can be also be freely obtained in most cases.

20. NICE GUIDELINES Who The National Institute for Health and Clinical Excellence (NICE) ---- the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health. What NICE produces guidance in 3 areas of health: • public health - guidance on the promotion of good health, prevention of ill health • health technologies - guidance on use of new and existing medicines, treatments, procedures within the NHS • clinical practice - guidance on appropriate treatment & care of people with specific diseases and conditions within the NHS. NICE categorises its guidance by health topic, type and date.

21. Developing NICE clinical guidelines This is a brief summary of how NICE develops clinical guidelines. • Guideline topic is referred.---by DOH • Stakeholders register interest. • Scope prepared ---This document sets out what the guideline will & will not - cover. • Guideline development group established. • Draft guideline produced. • Consultation on the draft guideline ---At least one public consultation period for guideline. An independent guideline review panel reviews the guideline. • Final guideline produced. • Guidance issued.

22. Benefits of implementation Implementing NICE guidance benefits everyone - patients, carers, the public, the NHS. It helps ensure consistent improvements in people's health and equal access to healthcare.

23. CKS-Formerly Prodigy What is CKS? • The NHS Clinical Knowledge Summaries (formerly PRODIGY) are a reliable source of evidence-based information and practical 'know how' about the common conditions managed in primary care. • CKS is commissioned and paid for by NHS Evidence, a service provided by the National Institute for Health and Clinical Excellence. Who is it for? CKS is aimed at healthcare professionals working in primary and first- contact care.

24. What does CKS offer Knowledge on clinical topics Quick answers — concise summaries on how to manage over 500 clinical situations (scenarios) commonly encountered in primary and first contact care. Detailed answers — that clearly link recommendations to evidence & source documents. Practical 'know how' to put the recommendations into action. Patient information • Provided by the Arthritis Research Campaign (arc), Epilepsy Research UK, the Family Planning Association (fpa), and NHS Direct, to complement the clinical knowledge. KnowledgePlus • Highlights of Cochrane reviews published in Cochrane Library. • Current information on the incidence of common infectious diseases in your area. • Medico-legal guidance on common problems. • Feature on primary care laboratory testing. • Information and clinical advice about safe use of medicines from the MHRA. • Details of latest drug alerts issued by the MHRA.

25. Who is CKS for? CKS is primarily designed for: • General practitioners, GP registrars • Nurses working in Primary Care and Walk-in Centres • Pharmacists • Medical, nursing and pharmacy students • Medical librarians It is also a useful resource for: • Patients / Other healthcare professionals e.g. emergency care practitioners • NHS managers / Accident and emergency departments / Educational institutions • Those involved in the development of care pathways, protocols, patient group directions and clinical management plans

26. What is SIGN? • The Scottish Intercollegiate Guidelines Network (SIGN) ---formed in 1993. • Objective is to improve the quality of health care for patients in Scotland, through clinical guidelines containing recommendations for effective practice based on current evidence. • The membership of SIGN includes all the medical specialties, nursing, pharmacy, dentistry, professions allied to medicine, patients, health service managers, social services, and researchers. • SIGN guidelines --- developed by multidisciplinary working groups • Each guideline based on a systematic review and critical appraisal of the current scientific literature.

27. Recommendations for local implementation are made based on local needs, priorities, and resources. • National open meeting is held to discuss each SIGN guideline in draft form. • All SIGN guidelines are also independently reviewed by specialist referees. • 3 years after publication, the guideline is for review and updated where necessary taking account of newly published evidence. • SIGN guidelines are distributed within the NHS in Scotland via a network of Guideline Distribution Coordinators. • All SIGN guidelines can also be downloaded free of charge.

28. Conclusion • The implementation of clinical guidelines within a clinical governance setting requires time, enthusiasm, and resources. • Local groups should adopt pre-existing valid guidelines. • Implementation activity should draw on the available evidence. • Clinical guidelines can also be used within continuing medical education or to answer specific clinical questions .

29. Guidelines on the web • http://www.nice.org.uk National Institute for Clinical Excellence. • http://www.sign.ac.uk The Scottish Intercollegiate Guidelines Network (SIGN) • http://www.healthcentre.org.uk/hc/library/guidelines.htmUK and worldwide guidelines available on the Internet (not necessarily formally appraised or reviewed). • http://www.suffolk-maag.ac.uk/guidelinesA general practice development group has been established in Suffolk to examine all proposed guidelines to see whether they aresensible and relevant to Suffolk before they are introduced. • http://text.nlm.nih.gov/ftrs/pick?collect=ahcpr&t=924522691Clinical guidelines published by the US Health Agency, but not fully available on the web. • http://www.sghms.ac.uk/phs/hceu/nhsguide.htm The Health Care Evaluation Unit’s Critical Appraisal instrument is available on the Internet. Its aim is to encourage the systematic development of clinical guidelines in the UK and to provide a structured and transparent approach to their appraisal. It can be used by independent appraisers to assess existing guidelines or by guideline developers as an aide memoire.

30. Thank you