April 2009 Netta Conyers-Haynes, Principal Consultant, Communications Kaiser Permanente National Guideline Program (NGP): Implications of IOM CPG Standards Craig Robbins, MD, MPH KP Colorado-Family Physician Medical Director-KP National Guideline Program

Kaiser Permanente: Largest Non-Profit Health Care Program in the United States  Founded in 1945  8 regions in 9 states and District of Columbia  8.6 million members (as of 12/09)  15,129 physicians (as of 12/09)  164,098 employees (as of 12/09)  KP Care Management Institute (CMI)  KP National Guideline Program (NGP) Kaiser Foundation Hospitals Permanente Medical Groups Kaiser Foundation Health Plan Kaiser Permanente

Kaiser Permanente Evidence Network  15 KP National Evidence-Based Guidelines  Supported by full systematic reviews  3.5 staff FTEs dedicated to KP NGP work  1 Principal Consultant, 2 Evidence Analysts, 2 Project Managers  1.5 physician FTEs dedicated to KP NGP work  7 Physician EBM Methodologists  External Vendor: Doctor Evidence  Search & Data Extraction  Technology platform Data repository, analysis & documentation

KP National Guideline Program Portfolio  Asthma-Adult  Asthma- Child/Adolescent  ADHD  Breast Cancer Screening  Cervical Cancer Screening  Colorectal Cancer Screening  CAD  Depression  Diabetes  Dyslipidemia (Integrated CVD Risk Reduction)  Heart Failure  HIV/STI Screening & Prevention  Hypertension  Osteoporosis  Prostate Cancer Screening

IOM Clinical Practice Guideline Standards: Congruent Areas for KP  Establishing transparency  Management of conflict of interest  GDG Composition:  Multidisciplinary & balanced  CPG-SR intersection  Evidence foundations & strength of recommendations  Articulation of recommendations  Updating

IOM Clinical Practice Guideline Standards: Problem Areas for KP  GDG composition  Patient & public involvement  Strategies to increase effective participation of patient and consumer representatives  External review  No review outside KP  No posting for public comment

Kaiser Permanente National Guideline Program: Process & Methodology New Clinical Issue Scheduled Update Clinical Questions (CQ) Existing Guideline? CQ Match? Assess Guideline Acceptable? Existing SR by CQ? Assess SR Acceptable? New Relevant Studies? Evidence Search Abstract Article Review Inclusion/ Exclusion Data Extraction Critical Appraisal Qualitative/ Quantitative Synthesis Assess Evidence Quality Evidence Summary RationaleRecommendations Assess Implementability of Recommendations GDT Approval Internal Review GQ NGD Approval National Guideline Yes No Implementation  Overview Key to Abbreviations: CQClinical Question SRSystematic Review GDTGuideline Development Team GQGuideline Quality Committee NGDKP National Guideline Directors

Kaiser Permanente National Guideline Program: Process & Methodology New Clinical Issue Scheduled Update Clinical Questions (CQ) Existing Guideline? CQ Match? Assess Guideline Acceptable? GDT Approval Internal Review GQ NGD Approval National Guideline Yes Implementation Acceptable External Guideline  ADAPTE/AGREE

Kaiser Permanente National Guideline Program: Process & Methodology New Clinical Issue Scheduled Update Clinical Questions (CQ) Existing Guideline? CQ Match? Assess Guideline Acceptable? Existing SR by CQ? Assess SR Acceptable? New Relevant Studies? Evidence Summary RationaleRecommendations Assess Implementability of Recommendations GDT Approval Internal Review GQ NGD Approval National Guideline Yes No Implementation No Acceptable External Guideline Acceptable External Systematic Review No New Relevant Studies  Modified AMSTAR  GRADE

Kaiser Permanente National Guideline Program: Process & Methodology New Clinical Issue Scheduled Update Clinical Questions (CQ) Existing Guideline? CQ Match? Assess Guideline Acceptable? Existing SR by CQ? Assess SR Acceptable? Evidence Search Abstract Article Review Inclusion/ Exclusion Data Extraction Critical Appraisal Qualitative/ Quantitative Synthesis Assess Evidence Quality Evidence Summary RationaleRecommendations Assess Implementability of Recommendations GDT Approval Internal Review GQ NGD Approval National Guideline Yes No Implementation No Acceptable External Guideline No Acceptable External Systematic Review  Internal Systematic Review  GRADE

Kaiser Permanente National Guideline Program: Process & Methodology National Guideline Disease Management Accreditation (NCQA) Clinician & Staff Education Tools (Clinical Library) Patient Education Tools (KP.ORG, National Patient Instructions Regions (EHR, CDS, Operations)  Guideline Implementation Key to Abbreviations: EHRElectronic Health Record CDSClinical Decision Support KP.ORGKP publicly-accessible Internet site NCQANational Committee for Quality Assurance

CPG Challenges  Infinite needs/finite resources  Balancing rigor with efficiency  Updating requirements  Every 2 years?  Dynamic updating, based on evidence & impact?  Patient/public involvement  Rigor of external SRs/CPGs  Implementation of CPGs at the point of care

CPG Opportunities  Improved SR & CPG rigor & transparency  Common evidence-grading & recommendation strength framework  SR & CPG developer collaboration  Prioritize & coordinate topics  Avoid duplication  Target funding  Collaboration with performance metric developers

KP National Guideline Program  Questions?  My contact information: Craig Robbins, MD, MPH Phone: Address: E Harvard Ave, Suite 250 Denver, CO 80231