GUIDELINES ADVISORY COMMITTEE...1 Guidelines Advisory CommitteeAnnual Report 2005-2006 Ontario...

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GUIDELINES ADVISORY COMMITTEE Annual Report 2005-2006 Closing the Clinical Care Gap Best Evidence Best Practices Better Health

Transcript of GUIDELINES ADVISORY COMMITTEE...1 Guidelines Advisory CommitteeAnnual Report 2005-2006 Ontario...

Page 1: GUIDELINES ADVISORY COMMITTEE...1 Guidelines Advisory CommitteeAnnual Report 2005-2006 Ontario Medical Association Ministry of Health & Long-Term Care Guidelines Advisory Committee

GUIDELINES ADVISORY COMMITTEE

Annual Report 2005-2006

Closing the Clinical Care GapBest Evidence • Best Practices • Better Health

Page 2: GUIDELINES ADVISORY COMMITTEE...1 Guidelines Advisory CommitteeAnnual Report 2005-2006 Ontario Medical Association Ministry of Health & Long-Term Care Guidelines Advisory Committee

Guidelines Advisory Committee Annual Report 2005-20061

Ontario Medical Association

Ministry of Health & Long-Term Care

Guidelines Advisory Committee

3 Representatives from OMA

Dr. Chris CresseyDr. Tom Faulds

Dr. William Feldman

1 Representative OMA Board

(non-voting member)Dr. Chris Pinto

3 Representatives from MOHLTC

Ms. Brenda GluskaDr. Walter RosserMr. Greg Walsh

1 Representative ICESDr. Chaim Bell

ChairDr. Dave Davis

Executive DirectorMr. Yale Drazin

Program ManagerMs. Jess Rogers

Administrative CoordinatorMs. Lily Nguyen

Administrative AssistantMs. Jennifer English

Medical AdvisorsDr. Atul Kapur

Dr. Valerie Palda

Information SpecialistMs. Kelly Lang

Roster of GAC Reviewers

Ontario Guideline Collaborative (OGC) Cancer Care OntarioCollege of Physicians and Surgeons of Ontario (CPSO)Continuing Medical Education Departments of: • McMaster University • Northern Ontario School of Medicine • Queen's University • University of Ottawa • University of Toronto • University of Western OntarioInstitute for Clinical and Evaluative Sciences (ICES)Ontario College of Family Physicians (OCFP)Ontario Hospital AssociationThe Change Foundation

Table of Contents

1 Our Structure

2 A Message from the GAC Team

3 What is the GAC?

4 What We Do / Our Review Process

5 Pre-Op Report by GAC

7 Other Accomplishments

9 How to Get Involved

10 Looking Ahead

Our Structure

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Guidelines Advisory Committee Annual Report 2005-2006

A Message from the GAC TeamWhat is the Clinical Care Gap and What Are We Doing About It?Studies consistently demonstrate that clinicians and health care systems may be unaware of new evidence, do not agree with it, are unable to adopt it, or may fail to comply with it on occasionswhen it matters to patient care1. This “gap in care” exists in Ontario and elsewhere2. Addressing this gap is the business of theGAC – the Guidelines Advisory Committee – a joint effort of the Ministry of Health and Long-Term Care in Ontario and the Ontario Medical Association.

Documented in this Annual Report are two significant directionsthat the GAC has undertaken, consonant with our overall mission toshift the culture of health care to evidence-based practice:

To overcome information overload, we find and distill best evidence derived from clinical practice guidelines, and produce useful summaries of recommended evidence-based bestclinical practices.

We disseminate these summaries widely, using an extensivenetwork of colleague organizations and methods.

Through collaboration with our partners, we also attempt to understand barriers to evidence implementation and pro-actively undertake implementation strategies. These tooare documented in this report.

This report identifies and acknowledges the important contributions of many individuals and groups to the achievementsof the GAC: members of the GAC itself; the Ontario MedicalAssociation and Ministry of Health and Long-Term Care; theInstitute for Clinical Evaluative Studies (ICES); our many collaborative partners; and the staff of the GAC.

Clearly, this closing of the care gap is a huge task – a much bigger goal than we can accomplish on our own. We welcome allyour comments and suggestions.

Dr. Dave Davis, Chair

Mr. Yale Drazin, Executive Director

Ms. Jess Rogers, Program Manager

1 Pathman,D.E.; Konrad,T.R.; Freed,G.L.; Freeman,V.A.; Koch,G.G. The awareness-to-adherence model of the steps to clinical guideline compliance: the case of pediatric vaccine recommendations. /Medical Care/ 1996 Sep;34(9):873-89.

2 McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA. The quality of health care delivered to adults in the United States. /N Engl J Med/ 2003;348(26):2635-45.

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Guidelines Advisory Committee Annual Report 2005-2006

What is the GAC?The Guidelines Advisory Committee (GAC) is an independent partnership of the Ontario Medical Association and the Ontario Ministry of Health and Long Term Care (MOHLTC).

Our Mission Our mission is to promote better health for the people of Ontario by encouraging and enabling physicians and other practitioners to use evidence-based clinical practice guidelines, particularly thoseendorsed by the GAC for use in the Ontario context.

Assisted by the active participation of numerous partner organizations and individuals, we are enhancing awareness anduse of practice guidelines. We offer many ways for interested parties to become involved with us in improving healthcare outcomes.

To fulfill our mission, we engage in four core activities:Evidence Review and Endorsement• Identifying and evaluating evidence-based recommendations

for best clinical practices• Engaging healthcare professionals, organizations and project

partners in identifying topic areas for review by the GAC• Conducting literature searches for existing clinical practice

guidelines in topics areas under review by the GAC• Having practicing physicians review retrieved guidelines and

assess the rigor of development using the AGREE Instrument (www.agreecollaboration.org)

Summary Development•Summarizing evidence to highlight its usefulness and relevance

to clinical decision-making

Evidence Dissemination• Improving the availability and accessibility of evidence

Evidence Promotion and Implementation• Increasing the adoption of and adherence to evidence-based

recommendations in clinical decision-making

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Strategic Objective 1

Identify and evaluate evidence-based recommendations for best clinical practices

Strategic Objective 2

Summarize evidence to highlight its usefulness and relevance to clinical decision-making

Strategic Objective 3

Improve the availability and accessibility of evidence

Strategic Objective 4

Increase the adoption of, and adherence to, evidence-based recommendations in clinical decision-making

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Guidelines Advisory Committee Annual Report 2005-2006

What We DoWe identify, evaluate, endorse and summarizeclinical practice guidelines...• The GAC does not develop guidelines. It reviews the

literature for existing guidelines in a clinical topic area• Each guideline is reviewed independently by four

physician reviewers• GAC reviewers use an internationally validated guideline

assessment tool called the AGREE Instrument (www.agreecollaboration.org), to evaluate the guideline

• Guidelines are endorsed based primarily on the methodological rigour of the guideline development process, the quality of linkage between evidence and recommendations for best clinical practices, and applicability in Ontario

• Summaries developed by the GAC are based on the endorsed guideline(s)

…and encourage adoption of evidence in practice.We facilitate or coordinate the efforts of other stakeholders directly involved in evidence implementation.

We are always looking for partners to make evidence based recommendations for best practice more available, accessible and relevant to the clinical decision-maker.

Our Review Process1 Topic Selection

2 Guideline Literature Search and Retrieval

3 Critical Appraisal of Evidence

4 Endorsement Decision

5 Summary Development

6 Dissemination of Endorsed Summary

7 Implementation of Endorsed Summary

8 Evaluation and Feedback

Select

Search

Appraise

EndorseSummarize

Disseminate

Implement

Evaluate

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5 4

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Guidelines Advisory Committee Annual Report 2005-2006

PRE-OP Report by GACPRE-OP Testing in Ontario

Can a GAC-led intervention reduce inappropriate testing?Dr. Dave Davis, Chair, Guidelines Advisory CommitteeDr. Jan Hux, Institute for Clinical Evaluative Sciences

BackgroundThe excessive use of preoperative testing, especially routine chest X-Rays and ECGs for low-risk surgery, and wide variation in theiruse across the province, have been documented in Ontario hospitals, a finding which demonstrates a failure to adopt evidence-based clinical practice guidelines.

InterventionIn response to this gap in care, the Guidelines Advisory Committeeand its partners undertook a series of interventions to align theuse of routine ECGs and Chest X-Rays prior to low and intermediate risk surgery with best available evidence. Launched in May 2003, this multifaceted intervention comprised:providing hospital specific feedback on preoperative testing ratesto all Ontario hospitals (led by the Institute for Clinical EvaluativeSciences); identifying and training of a small number of key opinion leaders in the province; and developing a tool for assessing the need for preoperative testing.

In 2004, a province-wide hospital survey was conducted to examine whether the intervention had changed hospital policy. Of the 80 hospitals reporting, 25% indicated they already followed a pre-operative testing policy consistent with the evidence; a further 12% indicated they would not change their existing policy. However nearly half (46%) indicated that the intervention had caused changes in routine preoperative care.

Hospital FeedbackPhase 1

Feedback profiles mailed to hospitals (ICES - May 2003)

Phase 2

3 RemindersGuideline summariesClinical practice tool (grid) Phone follow up

Phase 3

Data re-run post-intervention(ICES – Early 2006)

Preoperative Testing Grid

Endorsed by GAC as consensus-based practice aidDisseminated to all Ontario hospitalsPromoted through various channels:

• GAC Website • Distribution at CME events• OGC partners Websites• Advertisement and article in OMR• Newsletters and other communication –

OGC partners Presentations

Eighty hospitals were surveyed about the effect that the testing utilization data and/or the grid had on hospital policy and practice.

77% responded to the telephone survey.12.50 % = no effect26.25 % = no effect: hospital already follows guidelines46.25 % = helped to change hospital policy

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Guidelines Advisory Committee Annual Report 2005-2006

ResultsSubsequently, ICES examined data for fiscal 2004/05 to measurethe effect of the interventions. While these data show no overallchange in the use of preoperative ECGs, a decrease in the use of chest x-rays was observed in the time period following theintervention (2.6% absolute reduction; 13% median relative reduction). For some individual procedures (eye surgery, for example), more significant reductions in routine chest x-ray usewere demonstrated. Further, institutions with high rates of chest x-ray use in the initial period had more marked decreasesfollowing the intervention (e.g. from over 40% testing rate to under 15%).

CommentWhile the overall changes were modest, hospitals with very high rates of chest x-ray use in the baseline period achieved substantial reductions in rates. This pattern of change is typical of feedback interventions which motivate outliers to modify their behavior butmay not have as strong an impact on providers in the averagerange. Why the same intervention produced apparently differenteffects on the use of chest x-rays and ECGs remains unclear.However, we note that the evidence-based recommendations forchest x-ray are both stronger and may be simpler to implementthan those for ECG. Moreover, since chest x-ray incurs not onlycosts to the system but exposes patients to small risks related toradiation exposure and false positives, physicians and patientsmay have been more inclined to adopt these changes.

Two qualifications to these results are noted: • Feedback packages were delivered to the hospitals in

May 2003, during the height of the SARS epidemic; this unanticipated distraction may have reduced hospitals’ ability to react to the feedback data. This suggests that the findings of reduced usage may be conservative estimates of the true impact of the intervention.

• The transition from ICD-9 to ICD-10 coding systems occurred in the interval between the intervention and the evaluation, possibly leading to a slightly different mix of procedures being included in each of the two time periods, thus altering our ability to detect and measure the true impact of the intervention.

More InformationThe GAC website www.gacguidelines.ca under Projects offersmore material, including the Preoperative Testing Grid.

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Guidelines Advisory Committee Annual Report 2005-2006

Other AccomplishmentsIn evidence review and endorsement:GAC has taken steps to assure that clinical recommendations are credible and linkedto evidence.Physicians using GAC-endorsed guidelines and summaries of clinical recommendations need to feel confident that they are current, credible and linked to quality evidence. GAC hasrefined our instruments and processes to ensure that:• Our search of the literature is complete and focused on

relevant clinical questions• The guidelines we endorse are of high quality and applicable

in the Ontario context, and• The quality and strength of the evidence supporting

the clinical practice recommendations they contain are clearly specified.

In addition, the GAC partners or consults with other national andinternational experts, to exchange information about evidencereview and implementation processes used throughout the world.Among our key contacts are the Canadian Agency for Drugs andTechnologies in Health (formerly CCOHTA/COMPUS), GuidelinesInternational Network, National Institute of ClinicalStudies/Australia, New Zealand Guidelines Group, NationalInstitute for Health and Clinical Excellence/ UK and the Agency forHealthcare Research and Quality/US, and others.

GAC has sought input on which clinical topics to reviewTopics are chosen for guideline search and review based on their clinical significance, the care gap between evidence and practice, existence supporting clinical research, and their economic challenges.

The GAC surveys our key stakeholders, including physicians atlarge, OMA Clinical Sections, officials of the Ministry of Healthand Long-Term Care, guideline reviewers and partner organizations, for advice on clinical topics requiring evidence review.

GAC toolkits have improved guideline developmentPhysicians will not use guidelines that are confusing, or hard to read or navigate. The GAC uses our experience in reviewingguidelines to recommend best practices in guideline development.We have launched a project to develop a toolkit to assist guideline developers to enhance the quality of their guidelinesand ensure they are evidence-based.

We have a standard search strategy

Our reviewers are practicing physicians in Ontario

The AGREE Instrument evaluates the methods

used in development of the guideline

15 Topics were endorsed (8 new and 7 updates)

We received input on over 20 topics in 05/06

8 New Topics are planned for 06/07

37 Topics will be updated in 06/07

The GAC and Canadian Medical Association

are working on an update to the handbook for

guideline developers and implementors

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In summary development:GAC guideline reviewers have contributed tosummary developmentBy offering our guideline reviewers opportunities for enhanced roles in GAC activities, we anticipate that the understanding and adoption of evidence in clinical practice among these physicianswill grow. One key opportunity for reviewers is to contribute to summary development, under the guidance of our MedicalAdvisors. Those interested in playing roles in GAC activities areinvited to click on Get Involved from the GAC website.

In evidence dissemination:The GAC launched a comprehensive strategy for evidence dissemination Effective communications, informed by and focused on the needs of our target audiences, can enhance awareness of the GAC, shape practitioners understanding of the role of evidence in providing care, and increase the adoption the evidence-based recommendations in clinical practice.

Towards that end, the GAC:• Launched a monthly e-Newsletter in July 2005. There are

currently over 500 subscribers• Made regular presentations and exhibits: at CME events,

the Saturday at the University series, and Ontario Medical Association Council meetings

• Collaborated with the provinces six medical schools to assist them in implementing GAC-endorsed guidelines in existing CME activities

In evidence promotion and implementation:To complement our evidence dissemination activities, the GAC has built the capacity and relationships with partner organizations to undertake focused initiatives to actively promote implementation of evidence-based clinical practices.

On an ongoing basis, the GAC:• Engages the Ontario Guidelines Collaborative (OGC) in

collective strategies to advance collaboration in evidence implementation and performance and quality improvementinitiatives.

• Works to strengthen the network of Educationally InfluentialPhysicians (EIs) throughout Ontario to enhance its potential role in local education, professional development, and quality improvement and best practices initiatives among physicians.

• Invites OMA Clinical Sections to provide input in topic identification, evidence review, summary validation anddissemination, and other aspects of GAC activity.

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16 Summaries were developed in

the 05/06 year

Launched monthly e-Newsletter in

July 2005 (over 500 subscribers)

Disseminated GAC summaries at 10 CME events

Presented at the ICES/MOHLTC Symposium

January 2006

Website usage maintained an

average 4500 unique visitors/month

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Guidelines Advisory Committee Annual Report 2005-2006

How to Get InvolvedThe GAC offers many ways in which you and/or your organizationcan get involved in what we do. To learn more about these opportunities please visit the GAC website: www.gacguidelines.caand click on Get Involved on the right hand side of the screen.

Raise AwarenessJoin our e-Newsletter. Suggest websites/publications for GAC information to be posted.

Topic SuggestionPropose a TopicAre we missing an important clinical topic area? The GAC relies on physicians to let us know what topics they need more evidence on.

Formulate Clinical QuestionsWhat are the clinical questions that you ask yourself on a certaintopic? The GAC uses this input to guide its search of the literature as well as when it comes time to develop summaries. We want to meet your needs!

Suggest Tools/ResourcesA key to the use and adoption of evidence is the delivery and format of the information. We'd like to provide more tools andresources (eg. websites) on our site to assist physicians in the useof evidence in practice.

Disseminate Summaries• Email summaries to your colleagues• Integrate summaries into your teaching/curriculum• Let us know when you have used our material

Attend Educational Events• Participate in one of our annual workshops – held all

over Ontario!• Obtain accreditations • Request a Workshop• Attend a Videoconference

Become a ReviewerA critical step in the GAC review and endorsement process is engaging practicing physicians in the assessment of clinical practice guidelines in a topic area to determine the best guidelinesfrom those identified in the search process. Our reviewers are an asset to us particularly because their input is based on their clinical expertise and their applicability of evidence in practice.Reviewers assess the guidelines using the AGREE Instrument.

Criteria for Becoming a GAC Reviewer: • Practicing physician in the province of Ontario • Attend a GAC Reviewer Workshop

Put Guidelines into Practice• Suggest events where GAC could present• Identify potential collaborative opportunities for the GAC

Partner with the GAC on a Project?To discuss partnership opportunities contact the Executive DirectorYale Drazin at [email protected] or 416-946-7108

The GAC seeks to enhance the quality and value of the GAC experience, for physicians and other practitioners participating in GAC activities.

Workshops will be offered in 06/07 at eachMedical School across the province, for current and new GAC guideline reviewers.

Workshops Schedule for 06/07Ottawa – October. 13, 2006Kingston – December 1, 2006Toronto – February 23, 2007London – March 2, 2007

All workshops are from 9am – 4pmRegistration is $100 and includes lunch

Roster of GAC Reviewers

Dr. Tracey AsanoDr. Anthony ChinDr. Guilherme Coelho DantasDr. Michael De La RocheDr. David R. DixonDr. Janet DollinDr. Alexander FranklinDr. David Greg GambleDr. George HirakiDr. William HuDr. Heather KarnDr. Caroline KnightDr. Pierre KuglerDr. Bindu KumarDr. Famy Yim-LeeDr. Pamela LenkovDr. Dave LennyDr. Bruce LibermanDr. D’Arcy LittleDr. Manson M.T. MakDr. Heather McLeanDr. Patricia MousmanisDr. Didar N. OuladiDr. Roy M SaloleDr. Pierre SoucieDr. Janaki SrinivasanDr. J SzepsDr. Michael Varenbut

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Guidelines Advisory Committee Annual Report 2005-2006

Looking Ahead

Emerging opportunities for evidence-based initiativesOrganizational, professional and cultural trends in health care are creating new opportunities and needs for evidence based approaches.

The GAC will work with its partners in evidence implementationto respond to these emerging trends in:

• Models for service delivery: from individual physicians to multi-disciplinary teams;

• Approaches to patient management: from treating specific conditions to chronic disease management;

• Organization of care: from a focus on specific services to service integration;

• Innovation in health care management: from clinical to policy/program management

Encouraging a culture of evidence-basedchange in the provinceThe Guidelines International Network has planned its annualinternational meeting in Toronto for 2007! The GAC will co-hosts with the University of Toronto. G-I-N seeks toimprove the quality of health care by promoting systematic development of clinical practice guidelines and their applicationinto practice, through supporting international collaboration. This conference will bring together guideline developers, methodologists and guideline implementors from across theglobe. It is an excellent opportunity for the GAC, its partners andall others involved in guideline development and implementationto learn and share experiences.

To learn more about G-I-N, please visit their website atwww.gin2007.org

GAC Professional, Medical Advisory and Administrative Support Team $391,000

Administrative Expenses in Support of Core Services $73,400

Guidelines Search and Retrieval Process $83,500

Communication/Dissemination/Website $70,000

Partnership Development and Maintenance $66,000

Internal Project Implementation $10,000

Evaluation of GAC Performance and Products $5,000

Total Core Budget 05/06 $699,000

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Financial Information

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OMA/MOHLTC Guidelines Advisory Committee 500 University Avenue, Suite 650Toronto, ON M5G 1V7

Tel: 416-946-7899 • 1-888-512-8173 Fax: 416-971-2462Email: [email protected]

www.gacguidelines.ca

Best Evidence • Best Practices • Better Health