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Providing Expert Collaboration for the Development and Implementation of Evidence-Based Practices Rachel R. Walden, Jack Starmer, Robert Dittus, Zachary.

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Presentation on theme: "Providing Expert Collaboration for the Development and Implementation of Evidence-Based Practices Rachel R. Walden, Jack Starmer, Robert Dittus, Zachary."— Presentation transcript:

1 Providing Expert Collaboration for the Development and Implementation of Evidence-Based Practices Rachel R. Walden, Jack Starmer, Robert Dittus, Zachary E. Fox, Melissa McPheeters, Tracy C. Shields, Nunzia B. Giuse Vanderbilt University Medical Center May 2013

2 Clinical Practice Committee Collaborative effort to inform and standardize institution-wide evidence-based practice Implementation Integrates informatics, policy, and education approaches Information Experts Research and evaluation of existing evidence Methods Experts Inform research & statistical methods Clinical Experts Provide context Project Leaders Coordinate and communicate efforts, gain buy-in Enterprise Group Medical Center leaders who provide priorities & approval Institutional Experts Provide data on cost, use, and opportunities

3 Research Process Understand the topic, context, and timeline Search high-quality evidence-based guidelines and evidence reviews from USPSTF, NICE, AHRQ Search guidelines & evidence of unknown or lesser rigor from relevant organizations, PubMed, and Guidelines.gov Use primary literature for updates, clarification, specific questions Adapt process for different concerns and priorities Quality Review & Detailed Documentation

4 Routine preoperative chest X-ray Background research on rates of overuse Tier 1 resources: high-quality evidence-based guidelines and evidence reviews from USPSTF, NICE Tier 2 resources: guidelines & evidence from ACR, ACS, ASA, and other organizations, PubMed and Guidelines.gov search results Evaluation using AMSTAR, AGREE methods Primary literature: clarifying utility for lung cancer detection Quality Review & Detailed Documentation

5 Search: Systematic Reviews & Guidelines Tier 2 –Synthesized & Recommendation Resources of Unknown Quality Topic: Preoperative Chest X-RaySearch Dates: 4/10/2012-5/1/2012 (RRW) Source:Relevant Resources: PubMed (MEDLINE) Search for relevant systematic reviews, meta-analyses, guidelines Via Joo HS, Wong J, Naik VN, Savoldelli GL. The value of screening preoperative chest x-rays: a systematic review. Can J Anaesth Jun-Jul;52(6): PubMed PMID: Calderini E, Adrario E, Petrini F, Salvo I, Solca M, Bonomo L, Vanzulli A, Davini O, Pedicelli G; SIAARTI; SIRM. Indications to chest radiograph in preoperative adult assessment: recommendations of the SIAARTI-SIRM commission. Minerva Anestesiol Jun;70(6): English, Italian. PubMed PMID: Some additional references address specific surgeries and routine testing, such as renal transplant, oncologic, cataract surgery, etc. Search Strategies Employed: ("Preoperative Care"[mh] OR preoperative[tiab] OR pre- operative[tiab] OR "before surgery"[tiab]) AND (chest[tiab] OR Thorax[mh]) AND (Radiography[mh] OR "X-Rays"[mh] OR x- ray*[tiab] OR radiograph*[tiab] OR "CXR"[tiab]) AND ((Meta- Analysis[ptyp] OR Practice Guideline[ptyp] OR Guideline[ptyp]))

6 Organizational Guidelines Tier 2 –Synthesized & Recommendation Resources of Unknown Quality Topic: Preoperative Chest X-RaySearch Dates: 4/10/2012-5/1/2012 (RRW) Source:Relevant Resources: Relevant organizations Check for practice guidelines, committee opinions, statements American College of Radiology American College of Surgeons American Society of Anesthesiologists American College of Chest Physicians American College of Physicians international radiology, surgery, or anesthesiology organizations – selected organizations identified via Google search and not exhaustive; expectation is that PubMed search would return relevant guidelines from additional organizations ACR Appropriateness Criteria: Routine Admission and Preoperative Chest Radiography. 2000, last reviewed [American College of Radiology] /quality_safety/app_criteria/pdf/ExpertPanelonThor acicImaging/RoutineAdmissionandPreoperativeChes tRadiographyDoc6.aspx /quality_safety/app_criteria/pdf/ExpertPanelonThor acicImaging/RoutineAdmissionandPreoperativeChes tRadiographyDoc6.aspx Date: 4/10/2012 Committee on Standards and Practice Parameters, Apfelbaum JL, Connis RT, Nickinovich DG; American Society of Anesthesiologists Task Force on Preanesthesia Evaluation, Pasternak LR, Arens JF, Caplan RA, Connis RT, Fleisher LA, Flowerdew R, Gold BS, Mayhew JF, Nickinovich DG, Rice LJ, Roizen MF, Twersky RS. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology Mar;116(3): [includes chest x-ray] Date: 4/18/2012

7 Choosing Wisely Documentation of all CW recommendations & associated references Evaluation of all references for type and quality of evidence, agreement with CW recommendation, Follow-up: more in depth review of specific topics may occur Quality Review & Detailed Documentation

8 Full document includes keywords, PICO, links, & additional commentary Choosing Wisely RecommendationReferenceSource RecommendationType of EvidenceComments Don’t order chest radiographs in children with uncomplicated asthma or bronchiolitis. 2 of 4: National Heart, Lung and Blood Institute, National Asthma Education and Prevention Program. Expert panel report 3: Guidelines for the diagnosis and management of asthma. Bethesda (MD): National Institutes of Health; 2007 Aug. 417 p. Report No.: generally agrees with CW for differential diagnosis of asthma; "Additional studies are not routinely necessary but may be useful when considering alternative diagnoses" and "Chest x ray may be needed to exclude other diagnoses." Does not include any mention of chest x-ray in the monitoring section of the recommendation. guideline based on a systematic review Addresses asthma only Don’t order chest radiographs in children with uncomplicated asthma or bronchiolitis. 3 of 4: Dawson KP, Long A, Kennedy J, Mogridge N. The chest radiograph in acute bronchiolitis. J Paediatr Child Health (4): Not a recommendation; study seems to support CW: no relationship between degree of hyperinflation or infiltration and severity of illness, negative correlation between absence of atelectasis and mild disease study reviewing 153 children admitted with acute bronchiolitis and had a chest radiograph Addresses bronchiolitis only

9 Lessons Learned Define approaches that account for time limitations Write methods documents for searching and synthesis Document, document, document Agree on “evidence” and advocate for quality Be clear about disclaimers, limitations Recognize that some topics have more impact, generate more enthusiasm than others Prepare in advance to take advantage of opportunities


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