Creating and adapting a high- quality national clinical guideline with limited resources Authors: Mario Tristan Anggie Ramírez Brian Alper Jonas R. Te Paske August 25th 2012 GIN Conference Berlin 2012 Authors: Mario Tristan Anggie Ramírez Brian Alper Jonas R. Te Paske August 25th 2012 GIN Conference Berlin 2012

Disclosure of Interests (last 3 years) No personal or professional situation that might reasonably be expected to affect views on the subject on which we are presenting. Editor-in-Chief, DynaMed Medical Director, EBSCO Publishing (full- time employee)

Costa Rica health authorities requested producing Clinical Guidelines for breast cancer treatment and for early detection. They said “We need IN IT the NEXT six months” !!! June 2010!!! The Challenge

“…he argues that using standard methods for updating the evidence was similar to reinventing the wheel because some one else is doing or has done what you are trying to do...” “…he argues that using standard methods for updating the evidence was similar to reinventing the wheel because some one else is doing or has done what you are trying to do...”

“…OUR FIRST scratch paper ABOUT the METHODS ” “…OUR FIRST scratch paper ABOUT the METHODS ”

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DynaMed is a point-of-care clinical reference Created by physicians and other health care professionals. > 3,200 clinically organized topics. Evidence-based: Systematic 7-step methodology Summarization and synthesis of best evidence and guidelines Updated daily. Rapid use: standardized templates, outline format, linking. Available via internet, mobile devices, and webservices.

Defining Evidence-Based for a Clinical Reference For DynaMed “evidence-based” requires 7 steps: 1. Systematically identifying all applicable evidence. 2. Systematically selecting the best available evidence from that identified. 3. Systematically evaluating the selected evidence (critical appraisal). 4. Objectively reporting the relevant findings and quality of the evidence. 5. Synthesizing multiple evidence reports 6. Deriving overall conclusions and recommendations from the evidence synthesis. 7. Changing the conclusions when new evidence alters the best available evidence.

Fig 1: Updating curves for relevant evidence (128 systematic reviews) by point of care information summaries (log rank χ2=404, P<0.001). ©2011 by British Medical Journal Publishing Group

Levels of evidence in DynaMed Based on Strength Of Recommendation Taxonomy (SORT) Level 3 (lacking direct) evidence No comparative data. No clinical outcome. Level 2 (mid-level) evidence Comparative data for clinical outcome. Any risk of bias identified on critical appraisal. Level 1 (likely reliable) evidence Comparative data for clinical outcome. No substantive risk of bias identified. Meets explicit criteria (valid methodology, adequate results) for type of clinical question (interventional, diagnostic, prognostic).

Evidence Grading Guía de Práctica Clínica Oncoguía de Cataluña (2008), Spain. EBM Breast Cancer Guideline. ID: ebm00543 ( ). Duodecim Medical Publications, (2009), Finland. Guideline: Management of Breast Cancer in Women 84 SIGN (2007), Scotland. Evidences Summaries Breast Cancer treatment DynaMed (2010). Evidences Summaries Breast Cancer Duodecim Medical Publications (2010), Finland. American Joint Committee on Cancer Staging Handbook. 7th Edition. (AJCC,2010). National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology (NCCN Guidelines™ 2010). Original research trials Guía de Práctica Clínica Oncoguía de Cataluña (2008), Spain. EBM Breast Cancer Guideline. ID: ebm00543 ( ). Duodecim Medical Publications, (2009), Finland. Guideline: Management of Breast Cancer in Women 84 SIGN (2007), Scotland. Evidences Summaries Breast Cancer treatment DynaMed (2010). Evidences Summaries Breast Cancer Duodecim Medical Publications (2010), Finland. American Joint Committee on Cancer Staging Handbook. 7th Edition. (AJCC,2010). National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology (NCCN Guidelines™ 2010). Original research trials

Clinical Guideline was a excellent example for us: “Evidence based clinical guidelines for preventing the thromboembolic venous diseases in different medical conditions” SOCIEDAD ESPAÑOLA DE TROMBOSIS Y HEMOSTASIA SOCIEDAD ANDALUZA DE ANGIOLOGÍA Y CIRUGÍA VASCULAR 2007

Recommendations validations by multidisciplinary experts

Evidence Body Recommendation 9 Likert Scale (RAND/UNCLA)

Results External peer reviewers and evaluators Nacional 94% International 96%

Products

CPG for Breast Cancer Treatment

Breast Cancer Treatment Guideline for patients

CPG for Breast Cancer Treatment pocket version

Algorithms

Results Time to complete: Effort spent: Currency: Comprehensiveness: User feedback: 5 months for training + evidence analysis 3 FTE for 6 months Most current content of 16 CPG`s All studies on MEDLINE + EMBASE search captured by DynaMed Clinicians changed from resistors to supporters

Lessons learned Usefulness of adapting from other guidelines. Usefulness of DynaMed for finding current, comprehensive, appraised, evidence. Efforts needed to map SORT to GRADE. Usefulness of including evidence in stakeholder feedback.

Questions

Danke Thanks Gracias Merci Grazzie Obrigado Shokrán Bedankt Tack Takk 감사합니다 ありがとうございました Danke Thanks Gracias Merci Grazzie Obrigado Shokrán Bedankt Tack Takk 감사합니다 ありがとうございました