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Transcript of Making guidelines for communicable disease prevention and control Preben Aavitsland Department of...
Making guidelines for communicable diseaseprevention and control
Preben Aavitsland
Department of Infectious Disease Epidemiology
Norwegian Institute of Public Health
at
EpiTrain V, Vilnius, October 22 2007
Contents
• Background– Bad practice
– Varying practice
– The need for evidence
• Ten steps for making guidelines
Good guidelines?
”If he vomits, he’s more likely to choke the vomitus. Also, he tends to keep his head turned to the same side – usually toward the centre of the room. This may flatten the side of his head.”
SIDS mortality in England and Wales
From text books...
• Recommended sleeping position in books on child care
Variation in prescribing of antibiotics for acute otitis media
Froom J et al. Diagnosis and antibiotic treatment of acute otitis media: report from International Primary Care Network. BMJ 1990;300:582-6.
Many questions
• Disinfection of apartments of tuberculosis patients?
• How many doses of BCG vaccine?• Disinfestation of madrass of persons with
headlice?• Postexposure prophylaxis against HIV?• Regular screening of dairy workers for
Salmonella? And teachers?• Antibiotics to contacts of meningococcal
disease patients?
Why do we do what we do?
• Directive from Ministry?
• Learnt in medical school?
• Read in text-books?
• Tradition?
• Logic?
• Discussions with colleagues?
• Read in medical journals?
Why are guidelines needed?
• Variation in practice
• Practice ineffective or worse
• Guidelines must be based on the best evidence available
Ten steps
1. Justify need and refine subject2. Set up project and working group3. Identify previous guidelines4. Define objectives and users5. Identify and assess evidence6. Translate evidence into guidelines7. Get external review8. Plan and conduct implementation9. Plan evaluation10. Plan updating
1. Justify need and refine subject
• Justify need based on– Size of problem (morbidity, mortality, costs)
– Lack of consensus and variation in practice
– Evidence of poor application of evidence
– Evidence of ineffective services
• Refine the subject– What is actually needed?
– Specify the problem area
– Talk to users of guidelines
2. Set up project and working group
• Define a project– Resources, mandate, time frame
• Identify stakeholders– Everyone whose activities will be covered by the
guidelines
• Set up project group– Stakeholders
– ”Experts” from several disciplines (multidisciplinary)
– Patient groups? NGOs?
• Clarify commercial and other conflicts of interest
3. Identify previous guidelines
• Ask stakeholders
• Search Internet and books– www.who.int
– www.cdc.gov
– www.ecdc.europa.eu
• If found, assess relevance and quality– If ok, maybe you do not need to continue
4. Define objectives and users
Objectives
• Describe problem, situations and desired change
• Define relevant evaluation indicators– Process
– Quality
– Outcome
Methods
• How will the guidelines be developed?
• Transparent
Users
• Whom are the guidelines for?
5. Identify and assess evidence
Find evidence
• Look first for systematic reviews (Cochrane Library) and other reviews
• Then look for controlled trials (PubMed)
• Check references
• Ask group members
Assess evidence
• Is the evidence relevant to our objectives?
• Is the evidence valid? (Are the studies sound?)
• Grade the evidence
Hierarchy of evidence
1. Systematic review of randomised controlled trials
2. Individual randomised controlled trial
3. Non-randomised trial
4. Observational study (case-control, cohort)
5. Expert opinion (unsystematic review)
6. Personal experience
Searching for systematic reviews
• Cochrane library
• www.mrw.interscience.wiley.com/cochrane
• Search Cochrane Database of Systematic Reviews
• For instance: Are antibiotics helpful against conjunctivitis?
Searching for randomised trials
• Search PubMed
• www.ncbi.nlm.nih.gov/entrez/
• Limit to randomised controlled trials
6. Translate evidence into guidelines
• Intepret evidence– The quality (grade)
– The applicability to our objectives
– Costs versus benefits
– Knowledge of health care system
– Beliefs and values of group members
Grading of recommendations
• Very strong recommendation– Grade 1 evidence + applicability + benefits outweighs
costs
• Strong recommendation– Grade 2 evidence + applicability + benefits outweighs
costs
• Medium strong recommendation– Evidence of grade 3 + applicability + benefits
outweighs costs
• Weak recommendation– Evidence of grade 4 or lower + applicability + benefits
outweighs costs
7. Get external review
• Extra check of validity, clarity and applicability
• Include either individuals or organisations– Experts in the area ”sensible?”
– Experts in guidelines making ”sound method?”
– Potential users ”useful?”
• May improve acceptability
8. Plan and conduct implementation
• Many guidelines are useless and do not work
• Health care personell’s behaviour is very difficult to change
• Identify and address barriers and opposition to change
• Use sufficient resources for implementation
• Make an implementation strategy
Factors to help implementation
• Ownership
• Stepwise implementation
• Local adjustments
• Economical incentives
• Supervision from above
• Support
• Design of guidelines
• Use of Internet
• Integration in continuing education
• Opinion leaders
• Mass media
9. Plan evaluation
• Consider the objectives of the guidelines
• Measure effect– Compare groups or time periods
(quantitatively)
– Measure users’ compliance and satisfaction
– Measure patient outcomes?
10. Plan updating
• Updating is always needed– Assure quality and
relevance– Include new evidence,
new comments and evaluation results
– Remove old truths– Keep the users’ trust
• Authors are responsible, but simpler process
• Make a plan for update and inform users
• Starting point either– when new evidence
becomes available,– when evaluation is
finished, or– at specified time
• Www guidelines are easier to update, but how announce?
Outline of guidelines
• Background
• Objectives of guidelines
• Users of guidelines
• Methods for making the guidelines
• Guidelines
• Updating plan
• (Implementation plan)
• Literature
Conclusions
• Guidelines are needed
• We need guidelines based on evidence
• We should follow the ten steps for making guidelines
• Good implementation is crucial