International Collaboration in Guideline Production Prof. Günter Ollenschläger, Chairman, Guidelines International Network Director, German Agency for Quality in Medicine Helsinki,

2 Happy Birthday to DUODECIM‘s Current Care Guidelines

Organisations / 26 Countries Co-Chairs 2004/2005: G.Ollenschläger, M. Mäkelä

4 International Collaboration in Guideline Production: Content Background of the guideline movement Towards international networking in CPGs Aims and scopes of G-I-N International programmes and projects

5 International Collaboration in Guideline Production: Content Background of the guideline movement Towards international networking in CPGs Aims and scopes of G-I-N International programmes and projects

6 Guideline Movement: History  National Institutes of Health (US) – consensus development programme (1977)  Consensus Statements in SWE (81), NL (82), DK (83), UK (84), FI (85), NO (86)  Guideline programmes in several Western countries (1990s) J. Burgers, Quality of CPGs, 2002

7 Number of references in MEDLINE according to year of publications using MESH term “guidelines or practice guidelines” N. Klazinga, Clinical Practice Guidelines – a relevant international topic ?

8 Generic reasons for interest in CPGs  Economic crisis in health care and focus on cost containment  Growing concern about variation of care  Extra-professional interest: purchasers (governments, insurance companies) and patients ( consumer movement)  Professional organisations‘ interest: presenting the state of the art to colleagues, patients, policy makers Feder, Burgers

9 QualityAssurance QualityImprovement Biomedical Research Clinical Trials Outcomes and Effectiveness Research Evidence Based Information Clinical Practice Guidelines Quality Measurement Guidelines aim at transferring evidence into recommendations on best medical practice as a basis of quality promotion J. Slutsky, US Guideline Clearinghouse,

10 International Collaboration in Guideline Production: Content Background of the guideline movement Towards international networking in CPGs Aims and scopes of G-I-N International programmes and projects

11 Factors for Success of CPGs The success and failure of clinical practice guidelines depend on their quality and medical value, social, legal and ethical aspects involved, their implementation in daily practice. Council of Europe Rec. No. R (01) 13

12 Key Points for CPG‘s Acceptance Clinical practice guidelines should link recommendations with underlying evidences deal with every day health care problems help professionals in providing best medical practice at minimal expenses give detailed description of best medical practice processes Grol et al 1998

13 Problems of Guidelines: Quality Deficits and Conflicting Recommendations 1.Missing links between recommendations and evidences 2. Few information on development process, sponsorship, implementation tools 3.Cost-benefit-questions often excluded as topics 4.Conflicting guidelines on relevant topics 5. More academic recommendations than help for every day practice

14 Worldwide Trends in CPGs FromTo regional guidelines from professional groups national guideline programmes informal consensus of experts evidence-based systematic consensus monodisciplinarymultidisciplinary focus on developmentfocus on implementation limited life-expectancy‘living guidelines’ paper versionsInternet guidelines for clinicianspatient versions and patient involvement I. Kopp, J. Burgers, Edinburgh 2003 based upon Burgers, Grol, Klazinga, Mäkelä, Zaat for the AGREE Collab. Int J Qual Healthcare 2003

15  Agree Collaboration Research Project, sponsored by EU Research Project, sponsored by EU  Council of Europe CPG Recommendation  Inter. CPG Network Towards International CPG Networking: Towards International CPG Networking: From Research Partnership to Institutionalised Collaboration Research, training on high quality CPG devel. / use Policy paper on CPG standards CPG information, dissemination, networking

16 NETHERLANDS DENMARK SWITZERLAND FINLAND ITALY USA Canada New Zealand GERMANY SCOTLAND SPAIN ENGLAND & WALES FRANCE The AGREE Collaboration

Scope & purpose 2. Stakeholder involvement 3. Rigour of development 4. Clarity & presentation 5. Applicability 6. Editorial independence Quality Aspects of Guidelines (Domains of the AGREE Instrument)

18  Agree Collaboration Research Project, sponsored by EU Research Project, sponsored by EU  Council of Europe CPG Recommendation  Inter. CPG Network Research, training on high quality CPG devel. / use Policy paper on CPG standards CPG information, dissemination, networking Council of Europe Rec. No. R (01) 13 Towards International CPG Networking: Towards International CPG Networking: From Research Partnership to Institutionalised Collaboration

19 Ethical, economic and legal environment Development Dissemination Implementation Monitoring Evaluation Review Topic selection Systematic Guideline Production and Use Patients Professionals Policy makers Optimal health care Resources Council of Europe: Rec 13, 2001

20 Council of Europe Rec. No. R (01) 13 Chapter I – Current policy practices Chapter II – Functions of guidelines Chapter III – Methodology of guideline development Chapter IV – Dissemination and implementation Chapter V – Further practical, social, ethical and legal issues Chapter VI – Guidelines and standards Appendix 1 – Guideline programmes and clearing houses Appendix 2 – Examples of levels of evidence in guidelines J. Burgers, Quality of CPGs, 2002

21 Council of Europe Rec. No. R (01) 13 J. Burgers, Quality of CPGs, 2002 The Committee of Ministers, Recommends that the governments of member states :..... ii. promote international networking between organisations, research institutions, clearing houses and other agencies that are producing evidence-based medical information ;.....

22 March 2001: The idea of an institutionalised Guideline Network is introduced in the discussions of the AGREE Collaboration October 2001: Council of Europe recommends networking in the CPGs field. Jan-March 2002 Survey on needs for a CPG network - SIGN (UK) / AEZQ (D). November 2002: G-I-N. 11 “AGREE” partners from 8 countries consent on a constitution for The Guidelines International Network G-I-N. The G-I-N Story (1)

23 February 2003 : G-I-N recognised as a Scottish Charity with 37 member organisations. October 2004 G-I-N has a membership of 52 organisations from 26 countries. G-I-N’s “International Guideline Library” on contains more than guidelines and guideline documents. The G-I-N Story (2)

24 International Collaboration in Guideline Production: Content Background of the guideline movement Towards international networking in CPGs Aims and scopes of G-I-N International programmes and projects

25 Objectives of G-I-N Quality improvement of healthcare by promoting systematic development, dissemination, implementation and evaluation of CPGs.

26 Need Assessment: Issues of G-I-N

27 Need Assessment: Key Projects of G-I-N

28 Aims of G-I-N Improvement / harmonisation of CPG methodology International collaboration –to avoid duplication of effort –to facilitate information sharing, education, knowledge transfer Prioritisation / support of CPG research Maintenance of (2.600 CPGs, language specific training materials, ….) Information and training via workshops, conferences

29 Components of G-I-N’s Database-driven Website

Clinical Guidelines... - Database - Background documents - Topic collection - Training material - Implementation tools - Language groups - CPG News

31 G-I-N‘s Strategic Direction (1) Continuously updating and enhancing the INTERNATIONAL GUIDELINE LIBRARY ( Developing RECOMMENDATIONS for CPG use (f.e. for the adaptation of CPGs between countries) Developing international programmes on CPG topics: > Background documentation / evidence tables > Consumers/ patients and evidence > Dissemination and implementation > Electronic decision support > Guideline research > Linking CPGs with reviews (Cochrane, HTA, CME, Qual.Promot.)

32 G-I-N‘s Strategic Direction (2) Joint Projects between member organisations: –Language specific CPGs and training materials: e.g. French, German, Dutch –Regional networks: e.g. Nordic countries, – CPG Adaption –CPG Appraisal using the AGREE Instrument –Standardised CPG formates –Living CPGs –Training by regional workshops Joint Projects with external partners –G-I-N / Cochrane –G-I-N / INAHTA –G-I-N / GRADE Annual Conferences Edinburgh (UK) 2003, Wellington (NZ) 2004, Lyon (F) 2005, Toronto (CA) 2006

33 International Collaboration in Guideline Production: Content Background of the guideline movement Towards international networking in CPGs Aims and scopes of G-I-N International programmes and projects

34 Systematic CPG Adaptation Find the guidelines Appraise the guidelines Analyse the content Permission to adapt Look at the gaps Look at the sources What are the cultural and consumer issues Develop Recommendations using CJF Z. Fras 2002 – C.Marshall 2003, G. Ollenschläger / R.Schaffler2004

35 CPG Short Version Key Information + Recommendations Level 1 CPG Long Version Level 1 + Judgements + Evidence Tables CPG Sources Evidence (e.g.Pubmed, HTA, G-I-N) Level 2 Level 3 Link Interactive CME Tool: WWW Education Patient Information Key Information + Comments + Sources Link Quality Measures Indicators + Criteria + Sources GuidelineImplementation Linking CPGs with CME, Pat.-Info, Qual.Promotion

36 Worldwide Trends in CPGs FromTo regional guidelines from professional groups national guideline programmes informal consensus of experts evidence-based systematic consensus monodisciplinarymultidisciplinary focus on developmentfocus on implementation limited life-expectancy‘living guidelines’ paper versionsInternet guidelines for clinicianspatient versions and patient involvement I. Kopp, J. Burgers, Edinburgh 2003 based upon Burgers, Grol, Klazinga, Mäkelä, Zaat for the AGREE Collab. Int J Qual Healthcare 2003

37 G-I-N Membership Organisational Members –non-profit-distributing bodies / organisations –working in the CPG field –committed to adopting evidence-based practice –transparent about its sources of funding Associate Members –Any other body or association –Any individual who is active in the CPG field (Only members get full access to the International Guideline Library)

38 What are CPGs ?...systematically developed statements to assist important professional and patient decisions about appropriate health care for specific clinical circumstances. Institute of Medicine: Clinical Practice Guidelines: Directions for a New Program. (1990) Guidelines for Clinical Practice: From Development to Use. (1992) Setting Priorities for Clinical Practice Guidelines. (1995) Washington DC: National Academy Press, Council of Europe Rec. No. R (01) 13