www.wspg.org.ukWest of Scotland Pain Group
www.nbpa.org.ukNorth British Pain
Association
GuidelinesWhat difference do they make?
a Dutch perspective
Raymond Ostelo, PhD, PT
EMGO Institute, VU University Medical CentreInstitute for Health Sciences, VU University
Acknowledgement: Maurits van Tulder, Arno Engers
Content
• Development of evidence based guidelines
• Implementing evidence based guidelines
• Some food for thought /challenges for the future
Why (on earth) do we need guidelines?
Many myths
Evidence based practice
Sackett et al. EBM, Churchill Livingstone, 1997
Conscientious, explicit and judicious use of
current best evidence in making decisions
about care of individual patients
Problem
• The evidence explosion• No individual care provider can be up to date
anymore
Need for systematic reviews
• Systematic
• Transparent
• Reproducible state-of-the-art summaries
Clinical guidelines
• Systematically developed statements to assist
practitioner and patient decisions about
appropriate health care
• Recommendations
• No protocols, no ‘law’
Development and Implementation Cycle
of
Guidelines
ImplementingEvidence
Building Evidence
SystematicalLiterature studies
Clinical guidelines
study the optimal implementation strategies
Audit / monitoring
Study the effect ofimplementation
define health care problem
Experimental studies Observational studiesEconomical evaluation
ImplementingEvidence
Building Evidence
SystematicalLiterature studies
Clinical guidelines
study the optimal implementation strategies
Audit / monitoring
Study the effect ofimplementation
Low Back Problem
Experimental studies Observational studiesEconomical evaluation
ImplementingEvidence
Building Evidence
SystematicalLiterature studies
Clinical guidelines
study the optimal implementation strategies
Audit / monitoring
Study the effect ofimplementation
Low Back Problem
RCTs on effectiveness & Cost effectiveness
ImplementingEvidence
Building Evidence
Sufficient number of systematic (or structured) reviews
Clinical guidelines
study the optimal implementation strategies
Audit / monitoring
Study the effect ofimplementation
Low Back Problem
RCTs on effectiveness & Cost effectiveness
ImplementingEvidence
Sufficient number of systematic (or structured) reviews
Clinical guidelines in the Netherlands:- GP (NHG) guidelines (updated 2004)- Physiotherapy (KNGF) (2001)- Occupational Physicians (NVAB) (1999)- Manual Therapy (NVMT) (2003)- DI Healthcare Imp. (CBO) (2003)- Dutch Health Council (2007)
study the optimal implementation strategies
Audit / monitoring
Study the effect ofimplementation
Low Back Problem
RCTs on effectiveness & Cost effectiveness
Some features of Dutch guidelines
• Mono disciplinary– GP (NHG) guidelines (updated 2004)– Physiotherapy (KNGF) (2001)– Occupational Physicians (NVAB) (1999)– Manual Therapy (NVMT) (2003)
• Multidisciplinary– Dutch Institute Healthcare Improvement (CBO) (2003)– Dutch Health Council (2007)
Some features of Dutch guidelines
• Different methodologies for development– Advisory committee and writing panel – Subcommittees who are responsible for different parts
• Different methodologies for grading the evidence– Strict criteria (e.g. at least 1 good quality systematic
review: ‘level 1’, use phrase ‘it has been shown’ for recommendation
– quality criteria and formulations more loosely used
One feature in common
• All are ‘evidence based’
An intermezzo
Jacob (1785-1863) & Wilhelm (1786-1859) Grimm
An evidence based fairy tale• Once there was… a guideline committee and they defined
the health care problem & searched for the evidence
• then summarized the evidence…
• Then the orthopedists, anesthesiologists & the neurosurgeons did not like the evidence that was not in favor of surgery
• They redefined the health care problem so that they could omit the unfavorable evidence
• They sponsored the guideline so the guideline committee (grudgingly) ‘agreed’
Clinical guidelines for the management of low back pain in primary care:an international comparison
Bart Koes, Maurits van Tulder, Raymond Ostelo,
Kim Burton, Gordon Waddell
Spine 2001; 26: 2504-13.
Sources for differences in recommendations
• health care systems (organisation / financial)
• target population (e.g., GPs, physiotherapists)
Sources for differences in recommendations
• health care systems (organisation / financial)
• target population (e.g., GPs, physiotherapists)
• magnitude of effects
• (in)completeness of evidence
• methods of grading the evidence
• membership of guidelines committees
Clinical Judgment
Evidence based guidelines
Or
Evidence biased guided lies
Implementation
of guidelines
BackgroundRoom for improvement in adhering to the GP guideline
• Referral to physiotherapy for acute LBP pain• Time contingent approach
– medication– bed rest
• Medication– First choice: paracetamol – Second choice: NSAID’s
A multifaceted implementation strategy: aims
• Enhance patient education skills
• Improve referral practices for MT and PT
• Increase the use of written information (pamphlets)
• Increased knowledge of the guideline & relevant
scientific evidence
Why a multifaceted implementation strategy?
• Effective– Educational outreach visits – Multi professional collaboration– Financial interventions– Combined interventions
• Mostly effective– Interactive small group meetings– Mass media campaigns– Reminders– Computerized decision support
(Grol & Grimshaw. Lancet 2003; 362: 1225-30)
• 2 hour Workshop– Discussing relevant issues – Role playing with actor
• Providing pamphlets• Reminder with guidelines of Occup Phys and 2 articles
A multifaceted implementation strategy: training
Results
• A multifaceted intervention slightly modified the management behaviour of GPs in terms of fewer referrals to therapists during follow-up consultations
• It did not lead to more adequate provision of information to patients
Discussion
• GPs in control group also performed well– Is further improvement called for?
• Perhaps focus on situations where adherence to the clinical guidelines is known to be limited
113 PTs 113 PTs randomisrandomiseded
61 61 StandardStandard
DisseminatiDisseminationon
2 drop 2 drop outs outs
11 no 11 no data data
4 drop 4 drop outs outs
11 no 11 no data data
--
--
52 Active52 Active
ImplementaImplementationtion
N=3N=377
N=4N=488
PhysiotherapistsSame as Engers
Inclusion of patients
• New referral for non-specific low back pain
• Exclusion:– Specific low back pain– Pregnancy– Unable to complete questionnaires– No informed consent
Process-oriented outcome measures
• Blinded evaluation of registration forms by 2
researchers using algorithm for 4 key
recommendations:
– Limited number of sessions normal course– Goals focussing on activity and participation– Using active interventions– Giving adequate advise and information
Results process outcomes:% agreement with guidelines
26
79 77
96
42
12
7160
87
30
0
20
40
60
80
100
1 2 3 4 5
implementation
dissemination
1: ≤ 3 sessions 4: adequate information2: adequate goals 5: all recommendations3: active interventions
Results patient-centered outcomes
52 w eken12 w ekenbaseline
Lic
ha
me
lijk
fun
ctio
ne
ren
100
90
80
70
60
50
40
30
20
10
0
interventie
controle
Functional status (QBPDS)
Pain intensity (NRS)
52 w eken12 w ekenbaselineP
ijn
10
9
8
7
6
5
4
3
2
1
0
interventie
controle
Work absenteeism, coping, beliefs similar results
ll l l l l l
Conclusion• The implementation strategy
– slightly improved adherence to the guideline– did not result in additional beneficial effects on patient
outcomes
• Possible explanation: contrast in adherence between the two groups too small
Discussion
• Active strategies for implementing seem (not only from these studies) not beneficial on patient outcomes
• Still there might be other good reasons for using an active strategy to implement guidelines
• In case of similar outcomes, a more transparent health care process or reduction in costs can be reasons to recommend this strategy broadly
Food for thought
• Development
– Think before you leap: www.agreecollaboration.org
– Clinical guidelines are based on systematic reviews
(and/or individual studies) plus clinical expertise
– Saying an guideline is evidence based doesn’t make it
evidence based by itself
– Do weed need mono- or multidisciplinary guidelines?
More food for thought
• Should we adapt existing guidelines or develop
them all over again?
• Implementation of guidelines challenge for the
near future especially for practitioners not
participating in trials
Key messages
Development:
Adhere to guidelines for development
Dissemination should be planned, targeted and evaluated & needs to be supplemented by active implementation strategies
Raymond Ostelo
EMGO Institute, VU University Medical Centre
Institute for Health Sciences, VU University
