How to Overcome Barriers and Develop Collaborative Guidelines Amir Qaseem, MD, PhD, MHA, FACP Chair, Guidelines International Network Director, Clinical Policy, American College of Physicians

Conflicts of Interest Financial: None Non-financial:  Guidelines International Network (G-I-N)  Institute of Medicine (IOM)  Centers for Disease Control and Prevention (CDC)  National Quality Forum (NQF)  American Quality Alliance (AQA)  DECIDE project

The Need for Collaboration (Prostate Cancer Screening) ACPM concludes that there is insufficient evidence to recommend routine population screening with digital rectal exam or prostate specific antigen. ACS recommends that prostate cancer screening should not occur without an informed decision-making process. Men at average risk should receive this information beginning at age 50 years. Men in higher risk groups should receive this information before age 50 years. ACPM American College of Preventive Medicine ACS American Cancer Society

The Need for Collaboration (Prostate Cancer Screening) AUA recommends that early detection and risk assessment of prostate cancer should be offered to asymptomatic men 40 years of age or older who wish to be screened and have an estimated life expectancy of more than 10 years. USPSTF recommends against PSA-based screening for prostate cancer. AUA American Urological Association USPSTF United States Preventive Services Task Force

The Need for Collaboration (Prostate Cancer Screening) EAU recommends the decision to undergo early PSA testing should be a shared decision between the patient and his physician based on information balancing its advantages and disadvantages. CCA recommends insufficient evidence for population based screening. EAU European Association of Urology CCA Cancer Council Australia and Andrology Australia

Screening for Colorectal Cancer: Qaseem et al: Ann Intern Med. 2012;156(5):

The Need for Collaboration Target Audience  Clinicians (Advanced Practice Nurses, Allied Health Personnel, Nurses, Physicians)  Patients  Health Insurers  Policy Makers

Process of Collaborative Guideline Development Topic selection & key questions Identification of relevant stakeholders Establishing the ground rules

Establish the Ground Rules for Collaboration Financial Support Dissemination Guideline Development Group Conflicts of Interest Memorandum of Understanding (MOU) Timeline

Establish the Ground Rules for Collaboration Evidence and outcomes  KQ & clinical outcomes  What kind of evidence base will be used?  How will recommendations be developed?  What grading system will be used?  What decision making process will be used?  How will you deal with disagreement on evidence or recommendations?  What processes need to be followed for each society to approve the guideline?

Benefits of Collaboration Reduce the number of guidelines and potentially differing recommendations on the same topic (harmonization) Conserve resources Incorporate more stakeholders in the development process, which results in a better and more widely accepted guideline Reach a larger, more diverse audience

Barriers & Hurdles Longer time to complete the guideline Compromise on methods/outcomes Challenge to arrive at consensus for difficult topics

Many Successful Examples… Diagnosis & Management of Patients with Stable Ischemic Heart Disease (American College of Physicians/American College of Cardiology Foundation/American Heart Association/ American Association for Thoracic Surgery/ Preventive Cardiovascular Nurses Association) Diagnosis and Management of Stable Chronic Obstructive Pulmonary Disease (American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society) Current Pharmacologic Treatment of Dementia (American College of Physicians and American Academy of Family Physicians) Diagnosis and Treatment of Low Back Pain (American College of Physicians and American Pain Society *Veterans Affairs/Department of Defense)