TEACH LEVEL II: CLINICAL POLICIES AND GUIDELINES STREAM Craig A Umscheid, MD, MSCE, FACP Assistant Professor of Medicine and Epidemiology Director, Center for Evidence-based Practice Medical Director, Clinical Decision Support Senior Associate Director, ECRI-Penn AHRQ EPC TEACH Plenary August 8th, 2013

2 Goal To gain knowledge, attitudes and skills required to develop and adapt clinical policies and guidelines for implementation in health care.

3 Faculty  Karen Schoelles, MD, MS Director, ECRI-Penn AHRQ EPC  Louise Falzon, MS Research Librarian, Columbia University, and BCBS AHRQ EPC  Ian Graham, PhD Vice-President, Knowledge Translation, Canadian Institutes of Health Research; and Associate Professor, University of Ottawa

4 Daily Schedule

5 An Illustrative Case: Surgical Site Infections

6 Defining the problem and building a team  Building a team to define and address the problem Multidisciplinary Executive sponsorship Consumers COI  Using evidence as part of the process Local Published  Frame or “fit” problem within priorities of leadership to motivate support and solutions Mitchell MD, et al. Int J Technol Assess Health Care. 2010;26(3): Harris C, Turner T and Wilkinson F. Guideline Development Toolkit Lavis JN, et al. Health Research Policy and Systems. 2009, 7(Suppl 1):S4 doi: / S1-S4.

7 PICO and Analytic Frameworks Samson D, Schoelles KM. J Gen Intern Med. 2012; 27(Suppl 1):S11–19.

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9 Pyramid: 3 dimensional “3-S” model linking study designs to electronic resources Silva SA, Wyer PC. The Roadmap: a blueprint for evidence literacy within a Scientifically Informed Medical Practice and Learning (SIMPLE) model. The International Journal of Person Centered Medicine (In press)

10 National Guideline Clearinghouse

11 PubMed: Guidelines and Reviews

12 Cochrane Library: Reviews and HTAD

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14 Trustworthy Guidelines

15 IOM IOM domains 1. Establishing transparency 2. Management of conflict of interest 3. Guideline development group composition 4. Clinical practice guideline - systematic review intersection 5. Establishing evidence foundations for and rating strength of recommendations 6. Articulation of recommendations 7. External review 8. Updating

16 AGREE II Instrument  Tool to assess the quality of clinical practice guidelines.  Composed of 23 items in 6 domains: Scope and purpose (3 items) Stakeholder involvement (3 items) Rigor of development (8 items) Clarity of presentation (3 items) Applicability (4 items) Editorial independence (2 items)  Two Overall Assessments: Rating of the overall quality of the guideline Whether the user recommends the guideline for use in practice AGREE II: Advancing guideline development, reporting and evaluation in health care. Brouwers et al., Journal of Clinical Epidemiology 63 (2010) 1308e1311

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18 Hospital-based Health Tech Assessment J Gen Intern Med. 2010; 25(12):1352–5

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20 Seven Key Steps for Systematic Reviews 1.Define the question 2.Establish eligibility criteria 3.Search literature 4.Extract data 5.Evaluate individual study quality 6.Synthesize data qualitatively and/or quantitatively (MA) 7.Explore heterogeneity

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24 CAN-IMPLEMENT©: a six step model

Tool 4.1o Recommendations Matrix (template)

26 Stream Objectives By the end of this workshop, participants in this stream will be able to: Knowledge 1.Describe how to define a health care problem and identify questions requiring guideline recommendations 2.Describe how to find, appraise, and adapt guidelines and systematic reviews for local use 3.Describe the principles involved in doing original systematic reviews of the evidence 4.Describe how to formulate actionable recommendations

27 Stream Objectives (continued) Attitudes 1.Recognize the importance of carefully defining questions prior to searching for answers 2.Recognize the importance of the contribution of multidisciplinary teams to getting the questions right 3.Recognize the importance of appraising the quality of guidelines when selecting a guideline to adapt 4.Recognize the importance of adapting guidelines to local context

28 Stream Objectives (continued) Skills 1.Frame questions using an analytic frameworks such as the PICO format 2.Develop efficient search strategies corresponding to the analytic framework 3.Use tools such as AGREE II to appraise guideline quality 4.Use tools such as AMSTAR to appraise the quality of systematic reviews 5.Use GRADE or similar principles to synthesize an evidence base and develop actionable recommendations 6.Use ADAPTE and Can Implement to adapt national guidelines for local use

29 Questions?