enGINe December 2009 - Guidelines International Network

ENGINE
the
The newsletter of the Guidelines International Network
DEC
2009
Dear Colleagues
Greetings from a very chilly Scotland. I hope
you all had a safe return from Lisbon and the
collaborative spirit is still strong.
Contents
Chair’s column
1
G-I-N website
2
News from members
3
Country update
4
G-I-N spotlight
6
G-I-N working groups
7
Networking with G-I-N
8
Dating agency
10
Literature update
11
International guideline library 13
Feedback
Chair’s column
I am delighted to be serving a second year as the
Chair of G-I-N at such an exciting time. The New
Year will bring our long awaited revised website
which will help to support the network more
effectively and will offer limited access to the
guideline library for non members - something
the membership had identified as an action they
wished to see. The New Year will also see the
establisment of a working group on adaptation,
following the incorporation of the ADAPTE
collaboration within G-I-N, and much more
activity on implementation and multi-disciplinary
working. More details on our strategy and plans
for 2010 and beyond will be featured in the next
edition of enGINe.
I am pleased to inform you that the Board has
been strengthened by the co-option of two
members: Hayfaa Wahbi from Sudan and Saudi
Arabia and Günter Ollenschläger - co-opted as
Treasurer. We welcome Hayfaa to the Board for
the first time and we welcome Günter back.
Finally a few words of thanks – to Antonio and his
team for a great conference in Lisbon, to the old
Board and the G-I-N team for their support over
the last year, to the new Board for allowing me
to continue as Chair and to all of you for making
G-I-N a real Network. I would also like to pay a
particular tribute to Jean Slutsky. Jean has been
with the G-I-N Board right from the start and has
brought ideas, enthusiasm and practical support
to our work. We are delighted that she is joining
Catherine Marshall and Günter Ollenschläger as a
G-I-N Honorary Patron.
For many of us this time of the year brings a
number of big celebrations. Whatever form these
take for you – have a great time!
14
1
G-I-N Website
We are delighted to inform you that the new G-I-N website will be launched on January 15th 2010 .
Watch out for it and its new exciting features!
Important information:
• Our web address will remain the same
• G-I-N members will keep the same usernames and passwords
• URLs will change and although there will be automatic redirection to some new pages, especially
to the search page of the international guideline library, if you have bookmarked some specific
sections or have links to existing pages, you may wish to ensure that they are still working after the
launch
A test site is available for consultation and we welcome comments to support further improvement of
the site. Contact us if you would like to have a test member’s access.
Updating the international guideline library
To ensure that the international guideline library is kept up to date we ask our members to please let
our webmaster, Inga Koenig, know about any new or updated publications (like guidelines, systematic
reviews, evidence reports, guideline clearing reports), changes to your organisation’s contact details,
newsletter services or any other information you would like to present on the website, such as training
materials or projects. As always we are dependent on member organisations to keep the website up-todate.
Inga Koenig:
Phone: +49-30-4005-2522
Email: [email protected]
2
News from members
Shaikh BaHamdan Research Chair for Evidence-Based Health Care and Knowledge Translation
Shaikh BaHamdan Research Chair for Evidence-Based Health Care and Knowledge Translation (EBHC-KT)
is part of King Saud University programme to promote research at national, regional and international
level.
The Chair was established in June 2008 to foster the culture of evidence-based healthcare and work
towards bridging the gap between evidence and clinical practice through conducting research and
establishing bridges of communications with healthcare professionals, the academic organisations, the
policy makers and the community at large. It is meant to be a neutral, reliable source, and its activities
and the quality of its results will enhance the performance of the health system and make EBHC a
reality through creative initiatives, new mechanisms, research, education, networking, coordination,
integration and exchange of reviews, information and experiences. This would be fulfilled through:
1. Conducting EBHC-KT related research including primary studies, trials and systematic reviews.
2.Developing the EBHC culture by organising training courses for all sectors of healthcare providers
and healthcare policy makers.
3.Work towards introducing EBHC to under/post graduate curricula of medical colleges and allied
medical sciences colleges.
4.Promoting the use of evidence- based clinical practice guidelines (EB-CPGs) and facilitating the
development/ adaptation of EB-CPGs through training and support of healthcare professionals in
clinical settings.
5.Playing a central role in establishing and updating the standards of EBHC, sharing in performance
assessment and quality assurance and ensuring access to international professional and public
databases which provide evidence for decision making for healthcare professionals with a kingdomwide access.
6.Promoting the principle of partnership between patients and healthcare providers by provision
of tools such as evidence-based Arabic databases to enable patients to take decision in their
treatment.
7.Coordinating, fostering, and facilitating the exchange of scientific concepts and professional
opinion (networking) in EBHC-KT among the institutions and centres inside and outside the country.
For more information website: www.ksu.edu.sa/Pages/default.aspx
E-mail: [email protected]
Public Enterprise State Pharmacological Center of the Ministry of Health of Ukraine
The Public Enterprise “State Pharmacological Center” of the Ministry of Health of Ukraine is an institution
authorized by Ministry of Health to exercise administrative and economical regulation and control of the
registration of medicinal products.
The Center’s key functions are:
• E
xpert evaluation of materials related to development, production (manufacture), pre-clinical study
of medicinal products, clinical trials, regulatory and analytical support.
• S cientific expert evaluation of materials pertinent to development, pre-clinical study of medicinal
products aimed at their recommendation for clinical trials, evaluation of materials pertinent
to active substances, excipients used in the manufacture of medicinal products and giving
recommendations to the Ministry of Health of Ukraine concerning the possibility of their use and
registration.
• A
rrangements for specifying laboratories and settings involved by the State Pharmacological Center
to its activity pertinent to pre-clinical and clinical trials, quality assurance, validation of methods for
quality testing of medicinal products and their production.
• S cientific substantiation of the priority developments of new medicinal products and prognosis for
their need by Ukraine’s population.
3
• S tudy of the international experience regarding registration and expert evaluation of materials
pertinent to medicinal products.
• D
evelopment of documents in the field of standardization of medical services, including guidelines,
standards, and clinical protocols, concerning the rational pharmacotherapy, and quality indicators
of medical care.
• P
rovision of the development of the State Medicines Formulary and implementation of the
Formulary system.
• Provision of the information for the rational use of medicinal products in the health care system.
www.pharma-center.kiev.ua/
Country update • Latin America
Colombia: moving towards
evidence based healthcare model
In Colombia, benefit plans are being updated
by pathology prioritisation, along with the
simultaneous development of management tools
such as clinical practice guidelines (CPGs), in order
to attain a greater level of comprehensive care
coverage and to improve the quality of care while
efficiently rationalising health expenditures.
The overall strategy of the Colombian Health
Ministry for changing and improving the benefits
of healthcare plans is to:
• update the prioritisation of health problems
• r eview and update the contents of the plans
in light of scientific evidence and the CPG
• r espond to epidemiological and demographic
changes in the Colombian population, ie
changes in habits, the effect of increased
life expectancy and the slow aging of the
population
• d
evelop economic evaluations of the
prioritised pathologies and the financial impact of imposing the recommendations.
This strategy empowers CPGs as an instrument that gives conceptual clarity to health insurance in
Colombia and the UPC as a conduit for directing financial incentives. A CPG is not only a means of
improving quality, but also an efficient rationalisation of health expenditures.
While Colombia has had a fruitful experience in the development of guidelines, the proposal of the
Ministry of Health is to strengthen the component of evidence-based guidelines, economic studies and
resulting financial impact as a pragmatic solution in the absence of better alternatives
The development of evidence-based guidelines has been the initiative of academic groups. The Ministerial
strategy promotes the development of evidence-based guidelines for prioritised pathologies, including health
economic studies and an actuarial analysis of its impact on the UPC. The objectives are strengthening the quality
of care, and controlling the costs and increasing expenditures related to healthcare.
Some challenges must be addressed: the poor practice of information and record keeping, the availability of
health economists with the required expertise, as well as actuaries able to sequentially address the guidelines
that are part of the strategy. Finally, there is ignorance as to the true level of acceptance for the guidelines and
barriers of implementation.
However, the Ministry recognises the value and importance of evidence-based guidelines and interprets this tool
as a method not only for improving quality and cost containment, but also as a central element in the reform of
the mandatory healthcare plan for today’s Colombia.
4
Mexico: Coordinated production of clinical
practice guidelines in the public health system
The Mexican Ministry of Health, through the Innovation
and Quality Vice Ministry instructed the National
Center for Health Technology Excellence (CENETEC), to
coordinate the development of clinical practice guidelines
(CPGs) with the aim of establishing a national benchmark
to support clinical decision making and management
recommendations based on the best evidence available.
This in turn would reduce the use of unnecessary or
ineffective interventions and facilitate the treatment
of patients with maximum benefit, minimum risk and
acceptable costs.
The strategy devised to accomplish this challenge was
to establish collaboration among all the institutions
comprising the public health sector, for the adoption of
CPG with a common methodology and the creation of
a CPG Master Catalogue, coordinated by CENETEC. This
proved to be a task of great magnitude that has required
a complex coordination and sustained efforts from all
the participants in order to standardise and harmonise
criteria such as methodology and editorial format.
The effort has been fruitful and from May 2008 to November 2009 one hundred and fifteen CPGs were
produced and incorporated to the Master Catalogue as a result of the coordinated effort of more than 1,500
people. Themes were selected according to the health systems needs, starting with primary care and following
with specialty themes; all based on the best available evidence and aimed at improving the quality and safety of
medical assistance.
Guidelines in Brazil
In 2008 the population of Brazil was estimated at 189.6 million people. It is the fifth largest country in the world
and the fourth largest democracy. Brazil invests about 8% of its PIB in the health sector. In recent decades, the
cost has grown tremendously.
For years doctors in Brazil have been using international guidelines to support quality of care at their clinical
practice, although there is a growing trend to base the practice on the national guideline developed by the
specialty.
The Brazilian National Health System (SUS) was created with the goal of offering the population a free
comprehensive health programme, Ensuring universality and comprehensiveness in a country with inequalities
and scare budgetary and financial resources is an arduous task. The private health care sector has been growing
in Brazil with an increase in the number of insured in recent years.
There are several public and private initiatives that reinforce the importance of development and
implementation of guideline in Brazil. The Brazilian Medical Association (AMB) has set a priority agenda
with a view to equipping actors in both public and private health care systems with the tools necessary for
qualification of clinical practice and better care for the health of their participants.
The Brazilian Medical Association and the National Agency for Supplementary Health have joined G-I-N, and
are keen to network and share experiences, as happened at a workshop held in Rio de Janeiro. The workshop
was entitled “The Implementation of Clinical Guidelines in Health Care: international experiences and the issue
of private health insurance in Brazil,” and was held with the support of the Pan American Health Organization
(OPAS). It was an important step for all countries present – Brazil, Chile, Colombia and Portugal – and at the
same time showed that the organisation and use of clinical guidelines remains a challenge.
The Iberoamerican Guideline Network has been a very helpful support in the development and implementation
of guidelines in the region. At the Lisbon Conference the Boards of both organisations met in order to improve
liaison between G-I-N and the Iberoamerican Guideline Network.
5
In Brazil, the process of developing national clinical guidelines based
on evidence was triggered by the Brazilian Medical Association and
the Federal Council of Medicine in 1999. All directors of the AMB
and regional advisers of CFM voted unanimously in favour of the
partnership, outlining a policy of joint action. The subsequent
strategic planning carried out by the two entities ratified the key
objectives and action areas. Seven guidelines books have issued.
The Brazilian Medical Association (AMB) is developing clinical
practice guidelines with the Specialties Societies, coordinated
by a technical evidence based committee. To date about 400
clinical practice guidelines have been developed.
Guidelines from the Brazilian Medical Association
and the National Agency for Supplementary
Health (ANS) are available free of charge on the
site: www.projetodiretrizes.org.br.
ANS and AMB develop guidelines and monitor
their implementation. A priority-setting process
has been implemented based on the participation
of representatives of health insurance companies
and medical specialty societies. Priorities
included immunology, cardiology, endocrinology,
gastroenterology, geriatrics, internal medicine, medical
genetics, obstetrics and gynecology, oncology (breast, colon
and rectal, female genital tract), ophthalmology, paediatrics
and psychiatry. A list of 80 guidelines has been elaborated
and the collaboration will support their development and
implementation. The new process improves transparency
and seeks to improve the quality of health care by promoting
systematic development of clinical practice guidelines and their
application into practice.
If you would like your organisation and country to feature in
a future edition of ENGINE please contact the editorial team at
[email protected]
G-I-N Spotlight
G-I-N conference 2009: figures, feedback on the scientific poster competition
The 2009 G-I-N Conference held in Lisbon was truly international and enabled wonderful exchanges
between participants. We welcomed more than 380 delegates from 42 countries from all continents.
The outstanding work of Minna Kaila and the whole scientific committee was well rewarded by the
very positive comments offered by participants on the quality of the scientific programme. The scientific
committee selected wonderful plenary speakers, who highlighted the international outreach of G-I-N,
as they travelled from more continents than previously seen at a G-I-N conference. The committee
members reviewed more than 220 abstracts allowing us to hold 16 workshops and 19 parallel sessions
covering a range of topics from guideline development and implementation to patient and allied health
professionals involvement.
Amongst the many high quality posters, that of Anna Gagliardi (affiliate scientist from Toronto General
Hospital, Canada) won the poster prize this year for: “How can we improve guideline utilization?
Conceptual framework of implementability”.
The special social programme prepared for us by Antonio Vaz Carneiro and the local organisers enabled
further discovery of the Portuguese culture and networking at another level.
6
G-I-N Working Groups
G-I-N PUBLIC goes public!
The Guideline International Network Patient and Public Involvement working group (G-I-N PUBLIC) has
just published a research and practice agenda based on an international consultation exercise carried
out with guideline developers, patient/consumer representatives, and researchers:
Boivin A, Currie K, Fervers B, Gracia J, James M, Marshall C, Sakala C, Sänger S, Strid J, Thomas V, van
der Weijden T, Grol R, Burgers J, on behalf of the Guideline International Network Patient and Public
Involvement Working Group. Patient and public involvement in guidelines: international experiences
and future perspectives. Qual Saf Health Care. Accepted for publication (Nov 14, 2009).
Patient and public involvement themes were highlighted at the G-I-N conference in Lisbon: in addition
to the first plenary devoted to consumer involvement, three workshops and two breakout paper sessions
had consumer themes. Thanks to G-I-N and AHRQ support, two consumer representatives, Janet Wale
(from Australia and the Convenor of the Cochrane Collaboration CCNet), and Carol Sakala (from Childbirth
Connection in the USA and G-I-N PUBLIC steering committee member) contributed very positively to our
plenary session and workshops.
Three new people just joined our steering committee: Loes Knaapen from McGill University in Canada,
Mary Nix from AHRQ in the USA (replacing Marian James), and Corinna Scheffer from AZQ in Germany,
who replaces Sylvia Sänger. Our warm thanks go to Sylvia (our much appreciated past chair for 20092010) and Marian for their nice work with us over the past two years!
We have two main projects for 2009-2010: develop the first version of a toolkit on patient and public
involvement, and present a full day pre-conference workshop at the 2010 G-I-N conference in Chicago.
The toolkit and workshop will provide practical advice and tools to help guideline organisations develop
a patient and public involvement programme “from scratch” and improve the effectiveness of existing
involvement methods.
For more information on G-I-N PUBLIC, please visit www.ginpublic.net
7
Networking with G-I-N
Theme for the conference:
Integrating Knowledge. Improving Outcomes
August 25th to 28th 2010 • Chicago, Illinois, USA
Conference website: www.gin2010.org
Online abstract submission is open. Deadline for
submission of abstracts for oral presentations, posters or
workshops is 1st February 2010
Topics for submissions include:
• Synthesizing evidence (eg, meta-analysis, decision modeling)
• Evidence sharing
• Comparative effectiveness research
• Guidelines and patient safety
• Patient/family/stakeholders roles in guideline development
• Guidelines for allied health professionals
• Grading
• Incorporating resources/cost considerations into
guidelines
• Guidelines in developing countries
• Conflicts of interest in developing guidelines
• Guideline funding
• Publishing guidelines
• Computer-based decision support
• Performance measures and guidelines
• Incorporating guidelines into healthcare systems
• Implementing guidelines in developing countries
• Educating patients about guidelines
• U
ptake, impact and outcomes of guidelines
(indicators)
• Guidelines and public policy
Please consult the conference website for the full list of
topics and more information.
Note also that pre and post conference workshops/
training are under evaluation and preparation so mark
your calendars and visit regularly the conference website
for more information.
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Other events
10 December – 11 December 2009
Conference on Healthcare and Trade
Erasmus Expo and Conference Centre, Rotterdam, The Netherlands
20 January – 23 January 2010
3rd International Conference on Health Informatics
Valencia, Spain
25 February – 28 February 2010
International conference on Early Disease Detection and Prevention (EDDP)
Munich, Germany
5 May – 8 May 2010
3rd International Congress on Physical Activity and Public Health
Toronto, Ontario, Canada
www.cflri.ca/icpaph/fr/registration.php
15 May – 19 May 2010
ISPOR 15th Annual International Meeting: From Adaptive Trials to Personalized Medicine: Providing
Value for Decision-Makers
Hilton Atlanta, Atlanta, GA, USA
19 May – 20 May 2010
6th Annual World Health Care Congress - Europe 2010
Conrad Brussels, Brussels, Belgium
www.worldcongress.com/events/HR10015/index.cfm
26 May – 30 May 2010
19th Wonca World Conference of Family doctors – “The millennium development goals (mdgs): the
contribution of family medecine”
Convention center, Cancun, Mexico
6 June – 10 June 2010
HTAi 7th annual meeting: Maximising the value of HTA
RDS Conference Centre, Dublin, Ireland
11 July – 15 July 2010
20th IUHPE world conference on health promotion: health, equity and sustainable development
Geneva, Switzerland
18 August – 21 August 2010
World Cancer Congress: Prevention, treatment, supportive care, tobacco control: “Preventing the
preventable - Treating the treatable - Systems to make it happen”
Shenzhen Convention and Exhibition Centre, China
21 September – 24 September 2010
The 10th World conference on injury prevention and safety promotion
London, United Kingdom
6 October – 9 October 2010
16th Wonca Europe Conference: Family Medicine into the Future
Blending health and cultures
Malaga Conference Hall / Palacio de Congresos de Málaga, Malaga, Spain
10 October – 13 October 2010
ISQua’s 27th International Conference: Quality Outcomes: Achieving Patient Improvement
Marriott Rive Gauche Hotel, Paris, France
18 October – 22 October 2010
18th Cochrane Colloquium
Keystone, Colorado, USA
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Dating agency
We are pleased to let you know that Czech colleagues have asked for the newsletter to be translated
into their language. This initiative is encouraged and we are hoping that others may follow the trend.
Nevertheless we ask you to inform us ([email protected]) and to send back the translated piece to be
shared more widely via our new website!
Pre and Post-Conference workshops in Chicago?
Groups interested in running a workshop before or following the Annual G-I-N Conference in Chicago in
2010 are invited to submit their proposals to the G-I-N Executive Officer ([email protected]). To ensure proper
support and organisation we would appreciate if you could let us know rapidly of your intent to submit
a proposal and if you could send it to us by January 2010 at the latest.
The enGINe would like to know more about you!
Please get in touch to tell us about you, your organisation, your work programme, your ambitions.
Perhaps even your problems – the G-I-N community could have the answers you are looking for.
Note that requests of G-I-N members and partners are prioritised.
10
Literature update • December 2009
Joel E. Tepper and A. William Blackstock. Randomized Trials and Technology Assessment. Ann Intern Med 2009; 151:583-584.
Aaron L. Nelson, Joshua T. Cohen, Dan Greenberg, and David M. Kent. Much Cheaper, Almost as Good: Decrementally Cost-Effective
Medical Innovation. Ann Intern Med 2009; 151:662-667.
Under conditions of constrained resources, cost-saving innovations may improve overall outcomes, even when they are slightly less effective
than available options, by permitting more efficient reallocation of resources. The authors systematically reviewed all MEDLINE-cited cost–
utility analyses written in English from 2002 to 2007 to identify and describe cost- and quality-decreasing medical innovations that might
offer favorable “decrementally” cost-effective tradeoffs—defined as saving at least $100 000 per quality-adjusted life-year lost. Of 2128 costeffectiveness ratios from 887 publications, only 9 comparisons (0.4% of total) described 8 innovations that were deemed to be decrementally
cost-effective. Examples included percutaneous coronary intervention (instead of coronary artery bypass graft) for multivessel coronary
disease, repetitive transcranial magnetic stimulation (instead of electroconvulsive therapy) for drug-resistant major depression, watchful
waiting for inguinal hernias, and hemodialyzer sterilization and reuse. On a per-patient basis, these innovations yielded savings from $122
to almost $12 000 but losses of 0.001 to 0.021 quality-adjusted life-years (approximately 8 hours to 1 week). These findings demonstrate the
rarity of decrementally cost-effective innovations in the medical literature.
Joel E. Tepper and A. William Blackstock. Randomized Trials and Technology Assessment. Ann Intern Med 2009; 151:583-584.
Amy Folkes, Robin Urquhart, Eva Grunfeld. Are leading medical journals following their own policies on CONSORT reporting?
Contemporary Clinical Trials 2008;29(6): 843-846.
The revised Consolidated Standards of Reporting Trials (CONSORT) statement recognizes the importance of including data so that readers are
able to judge the reliability or relevance of randomized controlled trial (RCT) findings. However, it is unclear whether journals consistently
report the pre-randomization information necessary to assess the general applicability of trial results. The objective of this study was to assess
the extent of adherence to pre-randomization data reporting in 4 leading general medicine journals, as recommended by the revised CONSORT
statement over a specific time frame. A total of 480 RCTs met the eligibility criteria for review. In 2004, 138 of 246 (56%) articles reported the
full CONSORT pre-randomization information, of which 121 (88%) presented this information in diagram form. In 2006, 136 of 234 (58%)
reported the full information, of which 127 (93%) presented the information in a diagram. These numbers indicate no improvement in the
reporting of pre-randomization information. In conclusion, reporting of the full CONSORT data remains inconsistent. We recommend that
journals continue to support the CONSORT statement and ensure that adequate information is provided upon submission before commencing
the peer review process. The presentation of clear, precise data will ensure that readers are able to better interpret the applicability of
findings.
Tazeen H. Jafar, Juanita Hatcher, Neil Poulter, Muhammad Islam, Shiraz Hashmi, Zeeshan Qadri et al. Community-Based Interventions to
Promote Blood Pressure Control in a Developing Country: A Cluster Randomized Trial. Ann Intern Med 2009; 151:593-601.
Background: Despite convincing evidence that lowering blood pressure decreases cardiovascular morbidity and mortality, the hypertension
burden remains high and control rates are poor in developing countries. Objective: To assess the effectiveness of 2 community-based interventions
on blood pressure in hypertensive adults. Design: Cluster randomized, 2 × 2 factorial, controlled trial. (ClinicalTrials.gov registration number:
NCT00327574). Setting: 12 randomly selected communities in Karachi, Pakistan. Patients: 1341 patients 40 years or older with hypertension
(systolic blood pressure ≥140 mm Hg, diastolic blood pressure ≥90 mm Hg, or already receiving treatment). Measurements: Reduction in systolic
blood pressure from baseline to end of follow-up at 2 years. Intervention: Family-based home health education (HHE) from lay health workers
every 3 months and annual training of general practitioners (GPs) in hypertension management. Results: The age, sex, and baseline blood
pressure–adjusted decrease in systolic blood pressure was significantly greater in the HHE and GP group (10.8 mm Hg [95% CI, 8.9 to 12.8 mm
Hg]) than in the GP-only, HHE-only, or no intervention groups (5.8 mm Hg [CI, 3.9 to 7.7 mm Hg] in each; P < 0.001). The interaction between
the main effects of GP training and HHE on the primary outcome approached significance (interaction P = 0.004 in intention-to-treat analysis
and P = 0.044 in per-protocol analysis). Limitations: Follow-up blood pressure measurements were missing for 22% of patients. No mechanism
was detected by which interventions lowered blood pressure. Conclusion: Family-based HHE delivered by trained lay health workers, coupled
with educating GPs on hypertension, can lead to significant blood pressure reductions among patients with hypertension in Pakistan. Both
strategies in combination may be feasible for upscaling within the existing health care systems of Indo-Asian countries.
M Lugtenberg, J S Burgers, G P Westert. Effects of evidence-based clinical practice guidelines on quality of care: a systematic review. Qual
Saf Health Care 2009;18:385-392 doi:10.1136/qshc.2008.028043
Background: Evidence-based clinical guidelines aim to improve the quality of care. In The Netherlands, considerable time and effort have been
invested in the development and implementation of evidence-based guidelines since the 1990s. Thus far, no reviews are available on their
effectiveness. The primary aim of this article was to assess the evidence for the effectiveness of Dutch evidence-based clinical guidelines in
improving the quality of care. Methods: A systematic review of studies evaluating the effects of Dutch evidence-based guidelines on both the
process and structure of care and patient outcomes was conducted. The electronic databases Medline and Embase (1990–2007) and relevant
scientific journals were searched. Studies were only selected if they included a controlled trial, an interrupted time series design or a before
and after design. Results: A total of 20 studies were included. In 17 of 19 studies that measured the effects on the process or structure of
care, significant improvements were reported. Thirteen of these studies reported improvement with respect to some of the recommendations
studied. In addition, the size of the observed effects varied largely across the recommendations within guidelines. Six of nine studies that
measured patient health outcomes showed significant but small improvements as a result of the use of clinical guidelines. Conclusions:
This review demonstrates that Dutch evidence-based clinical guidelines can be effective in improving the process and structure of care. The
effects of guidelines on patient health outcomes were studied far less and data are less convincing. The high level of variation in effects
across recommendations suggests that implementation strategies tailored to individual recommendations within the guideline are needed to
establish relevant improvements in healthcare. Moreover, the results highlight the need for well-designed studies focusing on the level of the
recommendations to determine which factors influence guideline utilisation and improved patient outcomes.
11
Margaret B. Harrison, France Légaré, Ian D. Graham, Béatrice Fervers. Adapting clinical practice guidelines to local context and assessing
barriers to their use. CMAJ 2009.DOI:10.1503/cmaj.081232
Heejung Bang, Alison M. Edwards, Andrew S. Bomback, Christie M. Ballantyne, David Brillon, Mark A. Callahan et al. Development and
Validation of a Patient Self-assessment Score for Diabetes Risk. Ann Intern Med 2009;151:775-783.
Background: National guidelines disagree on who should be screened for undiagnosed diabetes. No existing diabetes risk score is highly
generalizable or widely followed. Objective: To develop a new diabetes screening score and compare it with other available screening
instruments (Centers for Disease Control and Prevention, American Diabetes Association, and U.S. Preventive Services Task Force guidelines; 2
American Diabetes Association risk questionnaires; and the Rotterdam model). Design: Cross-sectional data. Setting: NHANES (National Health
and Nutrition Examination Survey) 1999 to 2004 for model development and 2005 to 2006, plus a combined cohort of 2 community studies,
ARIC (Atherosclerosis Risk in Communities) Study and CHS (Cardiovascular Health Study), for validation. Participants: U.S. adults aged 20 years
or older. Measurements: A risk-scoring algorithm for undiagnosed diabetes, defined as fasting plasma glucose level of 7.0 mmol/L (126 mg/dL)
or greater without known diabetes, was developed in the development data set. Logistic regression was used to determine which participant
characteristics were independently associated with undiagnosed diabetes. The new algorithm and other methods were evaluated by standard
diagnostic and feasibility measures. Results: Age, sex, family history of diabetes, history of hypertension, obesity, and physical activity were
associated with undiagnosed diabetes. In NHANES (ARIC/CHS), the cut-point of 5 or more points selected 35% (40%) of persons for diabetes
screening and yielded a sensitivity of 79% (72%), specificity of 67% (62%), positive predictive value of 10% (10%), and positive likelihood
ratio of 2.39 (1.89). In contrast, the comparison scores yielded a sensitivity of 44% to 100%, specificity of 10% to 73%, positive predictive value
of 5% to 8%, and positive likelihood ratio of 1.11 to 1.98. Limitation: Data during pregnancy were not available. Conclusion: This easy-toimplement diabetes screening score seems to demonstrate improvements over existing methods. Studies are needed to evaluate it in diverse
populations in real-world settings.
Amit X Garg, Arthur V Iansavichus, Nancy L Wilczynski, Monika Kastner, Leslie A Baier, Salimah Z Shariff et al. Filtering Medline for a clinical
discipline: diagnostic test assessment framework. BMJ 2009;339:b3435.
Objective To develop and test a Medline filter that allows clinicians to search for articles within a clinical discipline, rather than searching
the entire Medline database. Design Diagnostic test assessment framework with development and validation phases. Setting Sample of 4657
articles published in 2006 from 40 journals. Reviews Each article was manually reviewed, and 19.8% contained information relevant to the
discipline of nephrology. The performance of 1 155 087 unique renal filters was compared with the manual review. Main outcome measures
Sensitivity, specificity, precision, and accuracy of each filter. Results The best renal filters combined two to 14 terms or phrases and included
the terms “kidney” with multiple endings (that is, truncation), “renal replacement therapy”, “renal dialysis”, “kidney function tests”, “renal”,
“nephr” truncated, “glomerul” truncated, and “proteinuria”. These filters achieved peak sensitivities of 97.8% and specificities of 98.5%.
Performance of filters remained excellent in the validation phase. Conclusions Medline can be filtered for the discipline of nephrology in a
reliable manner. Storing these high performance renal filters in PubMed could help clinicians with their everyday searching. Filters can also be
developed for other clinical disciplines by using similar methods.
Jeffrey M Drazen, Martin B Van Der Weyden, Paush Sahni, Jacob Rosenberg, Ana Marusic, Christine Laine et al. Disclosure of competing
interests. BMJ 2009;339:b4144.
John P.A. Ioannidis. Integration of evidence from multiple meta-analyses: a primer on umbrella reviews, treatment networks and multiple
treatments meta-analyses. CMAJ 2009 181: 488-493.
MaryAnn Foote. Backing Up Your Statements: How To Perform Literature Searches To Prove Your Points. Chest 2009;136:1432-1434;
doi:10.1378/chest.09-1615
Jared A. Blum, Kalev Freeman, Richard C. Dart, Richelle J. Cooper. Requirements and Definitions in Conflict of Interest Policies of Medical
Journals. JAMA. 2009;302(20):2230-2234.
Context Conflicts of interest (COIs) may influence medical literature. However, it is unclear whether medical journals have consistent policies
for defining and soliciting COI disclosures. Objective To determine the prevalence of author COI policies, requirements for signed disclosure
statements, and variability in COI definitions among medical journals. Design A cross-sectional survey of Instructions for Authors and manuscript
submission documents, including authorship responsibility forms, for high-impact medical journals across 35 subject categories available from
March through October 2008. Main Outcome Measure Presence of language referring to COI disclosure in the Instructions for Authors
or manuscript submission documents. Results Of 256 journals, 89% had author COI policies. Fifty-four percent required authors to sign a
disclosure statement, and 77% provided definitions of COI. Most definitions were limited to direct financial relationships; a minority of journals
requested disclosure of other potential conflicts such as personal relationships (42%), paid expert testimony (42%), relationships with other
organizations (26%), or travel grants (12%). The prevalence of policies varied by subject category: all internal medicine, respiratory medicine,
and toxicology journals studied had comprehensive COI definitions, with 19 of these 24 journals requiring signed disclosure attestations.
In contrast, 6 of 19 geriatrics, radiology, and rehabilitation journals requested author COI disclosure. Most journals that officially endorsed
International Committee of Medical Journal Editors guidelines had COI policies (68/69), compared with 84% of journals not endorsing the
guidelines (158/187). Conclusions In 2008, most medical journals with relatively high impact factors had author COI policies available for public
review. Among journals, there was substantial variation in policies for solicitation of author COIs and in definitions of COI.
12
International Guidelines library
New publications in the International Guideline Library – September 24th 2009 to November 11th 2009
ORGANISATION
TITLE
ASCO (US)
American Society of Clinical Oncology 2009 Clinical Evidence Review on
Radiofrequency Ablation of Hepatic Metastases from Colorectal Cancer
IQWiG (DE)
Aktualisierungsrecherche zum Bericht A05-19A (Cholinesterasehemmer bei Alzheimer
Demenz) - Rapid Report
[En: Update search on Report A05-19A (cholinesterase inhibitors
in the treatment of Alzheimer’s Disease) - Rapid report]
IQWiG (DE)
Bupropion, Mirtazapin und Reboxetin bei der Behandlung der Depression
[En: Bupropion, mirtazapine, and reboxetine in the treatment of depression]
IQWiG (DE)
Kurzwirksame Insulinanaloga bei Kindern und Jugendlichen mit Diabetes mellitus Typ 1 Nachfolgeauftrag
[En: Rapid-acting insulin analogues in children and adolescents
with diabetes mellitus type 1 – follow-up commission]
NICE (GB)
Bronchoscopic lung volume reduction with airway valves for advanced emphysema (IPG318)
NICE (GB)
Depression: the treatment and management of depression in adults (update) (CG90)
NICE (GB)
Guidance for employers on promoting mental wellbeing through
productive and healthy working conditions (PH22)
NICE (GB)
Lateral (including extreme, extra and direct lateral)
interbody fusion in the lumbar spine (IPG321)
NICE (GB)
Percutaneous intradiscal electrothermal therapy for low back pain (IPG319)
NICE (GB)
Photochemical corneal collagen cross-linkage using riboflavin
and ultraviolet A for keratoconus (IPG320)
NICE (GB)
Prasugrel for the treatment acute coronary artery syndromes
with percutaneous coronary intervention (TA182)
NICE (GB)
The treatment and management of depression in adults with chronic
physical health problems (partial update of CG23) (CG91)
NICE (GB)
Topotecan for the treatment of recurrent carcinoma of the cervix (TA183)
NICE (GB)
Topotecan for the treatment of relapsed small-cell lung cancer (TA184)
SCHIN (GB)
Amenorrhoea (CKS Topic)
SCHIN (GB)
Back pain - low (without radiculopathy) (CKS Topic)
SCHIN (GB)
Breast cancer - managing family history (FH) (CKS Topic)
SCHIN (GB)
Chilblains (CKS Topic)
SCHIN (GB)
Diabetes Type 2 (CKS Topic)
SCHIN (GB)
Eating disorders (CKS Topic)
SCHIN (GB)
Polycystic ovary syndrome (CKS Topic)
SCHIN (GB)
Schizophrenia (CKS Topic)
SCHIN (GB)
Tiredness/fatigue in adults (CKS Topic)
SCHIN (GB)
Urinary tract infection (lower) - women (CKS Topic)
SHdir (NO)
Retningslinjer for behandling av MS med immunmodulerende midler
[En: Guideline on the management of multiple sclerosis with immunomodulators]
SIGN (GB)
Management of attention deficit and hyperkinetic disorders
in children and young people (SIGN CPG 112)
SOS (SE)
Rekommendationer för vaccination mot den nya pandemiska influensan A (H1N1) 2009
[En: Vaccination recommendations for the new pandemic influenza A (H1N1) 2009]
ASCO (US).................American Society of Clinical Oncology
IQWiG (DE)................Institute for Quality and Efficiency in Health Care
NICE (GB)...................National Institute for Health and Clinical Excellence
SCHIN (GB)................Sowerby Centre for Health Informatics at Newcastle
SIGN (GB)..................Scottish Intercollegiate Guidelines Network
13
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