Guidelines in the United Guidelines in the United Kingdom and How They Are Kingdom and How They Are

UtilisedUtilised

Dr Paul Stevens

Kent Kidney Care Centre

United Kingdom

Lord Darzi: Next Stage Review

Word or phrase Number of mentions

Quality 359

Measures 23

Quality standards 4

Quality measures 3

Comparable measures 3

Quality metrics 2

Quality standards (set by NICE) 2

Clinical guidelines 0

Sustainability in the NHS – Guideline recycling

Talk Outline

• Guidelines: Plato or Playdough?

• History

• Methodology

• Implementation

• Closing the gap

• Guideline excellence

• Generalisability

Playdough (Play-Doh)

• Originally a putty-like wallpaper cleaner

• Named Play-Doh in 1955• Exported to Europe 1964• Play-Doh compound is

non-toxic, non-irritating & non-allergenic

Highly cost effective!

I think we’ll strip clinicians of their clinical freedom and determine majority views about practising medicine

Clinical guidelines help health professionals in their work, they do not replace their knowledge and skills

Guideline

NDTAJKD

JASN

CJASN

NEJM

Cochrane

PubMed

HTA

BNF

KI

JAMA

BMJ

Medline

DARE

DUETs

SIGN

Annals

Archives

AJN

Nephron

Google

NDT +

Multiple Sources of Information

Guideline process sorts, sifts, assesses quality and prioritises

UK Kidney Disease Guideline Groups

“NICE: A panacea for the NHS? No, but it should be useful for managing the introduction of new technologies”

“NICE may prove to be one of Britain’s greatest cultural exports, along with Shakespeare, Newtonian physics, the Beatles, Harry Potter, and the Teletubbies”

NICE Guidance in Kidney Disease

UK Renal Association History

“Thus when in October 1959 the Executive Committee received a letter from Dr [Frank] Parsons suggesting that a meeting should be devoted to a symposium on the artificial kidney. The Committee rejected this proposal.”

“A striking feature of the programmes of the Association during the 1960s is that still only 8 papers relating to dialysis were presented”

“papers on subjects relating to dialysis remained rare at the Association meetings for another decade more”

http://www.renal.org/pages/pages/the-association/history.php

Renal Association Memorial

UK Renal Association History

UK Renal AssociationClinical Practice Guidelines 4th Edition

Module DateReview

Due

Chronic kidney disease - led by Charlie Tomson, Maarten Taal

10/4/2007 2009

Complications - (CV disease, bone disease, anaemia, nutrition) - led by Mike Cassidy, Donald Richardson, Colin Jones

11/12/2007 2009

Blood-borne viruses – led by Colin Geddes 26/2/2009 -

Haemodialysis - led by Robert Mactier 26/3/2007 2009

Peritoneal dialysis - led by Simon Davies 15/5/2007 2009

Peritoneal access – led by Martin Wilkie 26/2/2009 -

Assessment for transplantation - led by Chris Dudley, Paul Harden

8/4/2008 2010

Acute Renal Failure (Acute Kidney Injury) - led by Paul Stevens, Andrew Davenport

8/4/2008 2010

http://www.renal.org/pages/pages/guidelines/current.php

UK Renal AssociationClinical Practice Guidelines 5th Edition

• Detection and management of CKD• Cardiovascular disease in CKD• Mineral metabolism in CKD• Nutrition in CKD• Anaemia in CKD• Infection control in the renal unit• Planning for renal replacement

therapy or conservative management in CKD

• Haemodialysis• Vascular access• Peritoneal dialysis• Peritoneal access• Evaluation of the kidney

transplant candidate• Medical management of the

kidney transplant recipient• Acute kidney injury

http://www.renal.org/pages/pages/guidelines/future.php

Due 2009/2010

• Key attributes for clinical practise guidelines

AGREE

• Scope and process – clearly defined

• Stakeholder engagement policy

• Rigorous development process –including systematic searching, inclusion/exclusion criteria etc

• Recommendations clearly presented

• Applicability considered

• Reliable – absence of bias

www.agreecollaboration.org

The Importance

of Evidence

Copyright ©2004 American Society of Nephrology

Strippoli, G. F. M. et al. J Am Soc Nephrol 2004;15:411-419

Figure 1. Number of randomized controlled trials (RCT) published in nephrology and 12 other specialties of internal medicine from 1966 to 2002

Pubmed Articles: Human Kidney Disease 1991 - 2008

Publication Year

Nu

mb

er

29 109 252

GRADE System

• Quality of evidence– High– Moderate– Low– Very low

• Strength of recommendation– Strong– Weak

Guyatt et al. BMJ 2008;336;924-926

• Individuals who insist that all interventions need to be validated by a randomised controlled trial need to come down to earth with a bump

Guideline Development Group

• Dr David Halpin, Chair • Dr Paul Stevens, Clinical

Advisor • Dr Eric Will, BRS• Professor Alison MacLeod

Cochrane Renal Group• Dr Mick Kumwenda, BRS• Dr Jonathan Evans, BAPN• Dr Paul Roderick, Public Health • Dr Penny Ackland GP • Dr Samir Agrawal,

Haematologist• Dr Shelagh O’Riordan, BGS• Dr Stephen Thomas, RCP• Mr Robert Dunn, NKF• Ms Christine Howard, NKF

• Ms Alison Roche, ANSA • Ms Carol Anderson, ANSA • Ms Karen Jenkins, RCN• Mr Robert Bradley, Renal

Pharmacist • Dr Nyokabi Musila, NCC-CC• Ms Debbie Nicholl Health

Economist• Mrs Alison Richards, NCC-CC• Mrs Bernadette Ford, NCC-CC• Dr Jane Fisher, NCC-CC• Mr Rob Grant, NCC-CCPlus• Ms Jane Alderdice, Renal

Dietitian• Project Executive

No Industry/Organisational Influence

• Moynihan R. Who pays for pizza? Redefining the relationships between doctors and drug companies. BMJ 2003;326:1189-1192

• Blumenthal D. Doctors and drug companies. N Engl J Med 2004;351:1885-1890

• Kassirer JP. How drug lobbyists influence doctors. Boston Globe. February 13, 2006:B9

• Campbell E et al. A National Survey of Physician–Industry Relationships. N Engl J Med 2007 356: 1742-1750

Review by Others

AGREE or Disagree?

AGREE Criteria NICE RA

Scope and purpose +++ +--

Stakeholder involvement +++- ++--

Rigour of development +++++++ ++++---

Clarity and presentation ++++ ++++

Applicability ++-- +--

Editorial independence ++ ++

20/23 14/23

So……Plato or Play-Doh?

• Plato aspects of guidelines unfetter your chains, set you free from blindness, foolishness, closed-mindedness, narrow-mindedness, and pride

• ‘Play-Doh’ aspects of guidelines afford you the creativity that is an essential part of early educational development and give you a new happiness from your discoveries

“We have the science of discovery but what we need is the science of implementation”

Lord Darzi

Implementation and Adherence

Implementation

MotivationAwareness and knowledge

PracticalitiesSkills

Acceptance and beliefs

Educational materials

Meetings

Outreach visits

Reminder systems

Opinion leaders

Patient mediated strategies

Clinical audit & feedback

Overcoming Barriers

Implementation

• Raised awareness

• Planning change

• Partial implementation in one area

• Full implementation in one area

• Full implementation across all areas

• Overcoming Barriers

Principles of Implementation

• Board support and clear leadership

• Provision of a dedicated resource

• Support from a multidisciplinary team

• Systematic approach to financial planning

• Systematic approach to implementing guidance

• Process to evaluate uptake and feedback.

Process for Implementing Guidance

Set up review

process

“Yes, but as part of an integrated care strategy”

Should We Follow Guidelines?

“We’ll think about it.”

The Renal NSF: Part 2

• Quality requirement 1: Prevention and early detection of chronic kidney disease (CKD)

• Quality requirement 2: Minimising the progression and consequences of CKD

April Fools Day 2006

eGFR reporting

QOF

Quality and Outcomes Framework

• The QOF is intended to measure, encourage and support clinical care and a patient experience which is constantly improving

Renal Indicators in the QOF

Indicator 1 Register of patients aged 18 years and over with CKD Stage 3-5

Indicator 2 % of patients on the CKD register with a record of blood pressure in the previous 15 months

Indicator 3 % of patients on the CKD register with a BP ≤140/85

Indicator 5 % of patients on the CKD register with hypertension and proteinuria who are treated with an ACEI/ARB

Indicator 6 % of patients on the CKD register with measurement of ACR in last 15 months

Guideline Referral Recommendations

• Stage 4 or 5 CKD ± diabetes

• High levels of proteinuria (ACR ≥70 mg/mmol)

• Proteinuria (ACR ≥30 mg/mmol) together with haematuria

• Rapidly declining GFR

• Refractory hypertension

• Suspected rare or genetic causes of CKD

• Suspected renal artery stenosis

020406080

100120140160180200

Kent Monthly New Referrals 2003-2008

August 03 – March 2006 April 2006 – August 2008

Hobbs et al, Unpublished data

Why Identify Chronic Kidney Disease?

Kent New Referrals by CKD Stage

Hobbs et al, Unpublished data

Late Referral: UK Renal Registry Data

%

Year

UK Renal Registry Report 2008

The Renal NSF: Part 1

1. Patient centred service

2. Preparation & choice

3. Elective dialysis access surgery

4. Dialysis

5. Transplantation

What is Audit?

• Awfully• Uninteresting• Deadly Dull• Immensely• Tedious

• Amazingly• Underutilised• Driver for• Improvement in• Treatment

Charlie Tomson, with thanks

Using National Audits to Drive Local Improvement

• If you cannot measure it, you cannot improve it – Lord Kelvin, 1824-1907

• Stages of facing reality:– “The data are wrong”– “The data are right, but it’s not a problem”– “The data are right; it is a problem; but it is not

my problem”– “I accept the burden of improvement”

Berwick D. Qual Saf Health Care 2003;12(S1):2-6

Shifting the Population MeanP

op

ula

tio

n n

um

ber

s

Decreasing mortality risk →

Audit in Nephrology

• No shortage of problems

• No shortage of audit standards/criteria

• Highly computerised

• Many numerical measures e.g. Hb, URR, PO4, % catheter use

• Very little evidence of implementation of change

%of Patients With URR >65

UK Renal Registry Report 2008

Unit Performance is a Stable Characteristic

The Centre Effect in RRT

• UKRR observes marked, stable (year on year) centre variation in– % URR >65– % Hb between 10.5 and 12.5 g/dL– % SBP < 140 mm Hg– Survival

Multidisciplinary learning session BRS, 12th June 2007

“All teach, all learn”

Learning session – that’s NOW!

Identify best-performing Units for each topic area; develop ‘change package’

Data from UKRR and other national audits

Multi-specialty improvement teams

Web-based social network allowing sharing of protocols, ideas, tests of change, RESULTS

Lessons learnt

• High-performing centres may not know what they do that others don’t

• Fostering collaboration requires continued input and a purpose-built website

• Teaching Quality Improvement methodology probably takes more than 60 minutes

Understanding the ‘Centre Effect’

• Differences in outcomes between centres that cannot be attributed to differences in case mix

• Structure + Process = Outcome• Requires detailed understanding of how centres

organise and deliver treatment– Qualitative research to identify candidate practice

patterns– Quantitative research to find out which practice

patterns are associated with the best outcomes

Door to Balloon Time (DTBT)

• Qualitative study of common approaches in hospitals that achieve rapid DTBT

• Quantitative study of 28 candidate practices: 6 strategies statistically significant:– ER physicians activate cath lab– Single call to switchboard to activate cath lab– Activate cath lab while patient en route to hospital– Expect staff to arrive within 20min of being paged– Attending cardiologist always on site– Real-time data feedback to ER and cath lab staff

Bradley JACC 2005; 46; 1236; Bradley NEJM 2006; 355; 2308

Closing the Gap: Aims

• Create quality improvement programmes in renal centres in England, Wales and Northern Ireland

• Maximise compliance with Renal Association Standards

• Devise a quality improvement model which is sustainable and transferable to similar organisations in the UK

Improving on League TablesPercentage of haemodialysis patients with serum phosphate

<1.8mmol/L

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65

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Lower 95% confidence intervalN = 17,319

Median rank for percentage of HD patients with phosphate<1.8mmol/L

0

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Upper 95%Confidence intervalMedian rank

Lower 95%Confidence interval

Standard ‘caterpillar’ plot

Monte Carlo analysis using 5000 samples from the distribution from each centre: median rank of each centre with confidence intervals

Summary (1): Evidence Into Practice

1. Summarise the evidence

2. Identify local barriers to implementation

3. Measure performance

4. Ensure all patients receive the intervention

Pronovost et al. BMJ 2008;337:a1714

Johns Hopkins evidence into practice model

Summary (2)

• High quality audit by direct extraction of data from clinical electronic records is feasible and generates tension for change

• Learning from high performance requires detailed understanding of structure and processes in high-performing centres

• Near-real-time statistical process control charts likely to stimulate and reward QI

8 strategies for Achieving Change

1. Make the desired action the default2. Steal ideas shamelessly3. Actively encourage collaboration4. Involve the people who do the work5. Spread successful new ideas rapidly6. Align financial incentives to quality7. Use patient power8. Raise expectations amongst

commissioners