Guideline

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Guideline Powered By Docstoc
					From guidelines to seamless
           care
           Minna Kaila, MD, PhD
  Chief Physician, Department of General
                  Practice
        Pirkanmaa Hospital District
                  Guideline?

 Clinical practice guideline

 ”Systematically developed statement, based on
  scientific evidence, on the diagnosis and
  treatment of a disease”
 To help decision making (physician, other health
  care professionals, patients)

 To improve quality in Health care
            Motivation for guidelines

 Study 1995: 719 guidelines & regional treatment programs in 5
  years
   – length, structure and quality varied
   – duplicate work
 Registry data on practice variation
   – elective procedures, e.g. cataracts, cesareans
   – medication, e.g. asthma, hypertension
 National strategy promoting EBHC
 Specialists interested in better guidelines

         Varonen & Mäkelä. Practice guidelines in Finland: availability and quality.
         Qual Health Care 1997;6:75-9
                Health policy
               or clinical
               decisions                                                                 Practical applications:
                                      Values             Resources                       Care pathways, training
                                                                                              programmes
                                            Evidence



                                                                                                   Evidence
                      Health technology
                                                        Clinical guideline                         Based
                                                                                                   Health
                        assessment

                                                                                                   Care
                                                                Systematic
                                                                  review



                             Systematic organisation of information


                                             Primary             Primary              Other
 Economic              Epidemio-
                                             clinical          laboratory            primary
evaluations            logic data
                                            research            research            research



              Study                 Study                                   Study          Study
www.agreecollaboration.org




Evaluation of guideline quality


                             13 translations
        Käypä hoito - Current Care
           Guideline Programme
 Medical Society Duodecim
 Specialist societies
 Funding: Ministry of Social Welfare&Health
 To
   – collect and update scientific knowledge of
     essential health problems
   – make the information available in health care
  – evaluate the effects
 Topics: common chronic conditions, new
  methods dgn/Rx, variation documented
             Publication – in Finnish
 Lääkärin CD-rom (EBMG) – most of PHC
    – innovative electronic publication since 1989

 Internet
    – http://www.kaypahoito.fi(free access)
    – http://www.terveysportti.fi(portal) – all hospital districts,
      most health centres

 Medical Journal Duodecim – almost all MDs
    – full guideline, summaries, update summaries

 Patient version in Hyvä Terveys – health magazine with widest circulation
 Updates in electronic format only (~3 years)
www.kaypahoito.fi
J.Briggs Inst.for Evid.Based Nursing&Midwifery, AUS
National Institute of Clinical Studies NICS, AUS
Austrian Ass.for Quality in Healthcare, A
Belgian Center for Evidence based Medicine, B
Flemish College of General Practitioners, B
Program in Evidence-based Care, Cancer Care Ontario, CDN
Danish Guidelines Secretariat, DK
Finnish Medical Society Duodecim, FIN
Finnish Office for HTA FINOHTA, FIN
French Nat.Agency for Accred., Eval in Healthcare ANAES, F
French National Federation of Cancer Research Centres, F
German Association of Scientific Medical Societies AWMF, D
Berlin Chamber of Physicians, D
German Agency for Quality in Medicine ÄZQ, D
Royal College of Surgeons in Ireland RCSI, IRL
Iceland Directorate of Health, ISL
Italian Evidence-Based Medicine Group GIMBE, I
Regional Health Agency Emilia-Romagna, I
Malaysian Ministry of Health, MAL
New Zealand Accident Compensation Corporation, NZ
New Zealand Guidelines Group, NZ
Norwegian Directorate for Health and Social Affairs, NO
Polish Institute for EbM, PL
Polish Soc.for Quality Promotion in Healthcare, PL
Portuguese Institute for Quality in Healthcare, POR
Slovene Guidelines Group, SLO
Basque HTA Office OSTEBA, E
Josep Laporte Library Foundation, Barcelona, E
Swedish Board of Health and Welfare (Socialstyrelsen), S
Clinical Epidemiology Center Lausanne , CH
Swiss Medical Association FMH, CH
                                                             Membership
Dutch Association of Comprehensive Cancer Centres, NL
Dutch College of General Practitioners, NL                   April 2003
Dutch Institute for Healthcare Improvement CBO, NL
National Institute for Clinical Excellence NICE, UK
Centre for Reviews & Dissemination York, UK
Scottish Intercollegiate Guidelines Network, UK
Sowerby Centre for Health Informatics at Newcastle, UK
Agency for Health Research & Quality AHRQ, USA
National Kidney Foundation, USA
                                                        www.g-i-n.net
AGREE Collaboration, INT
World Health Organisation Geneva WHO, INT
                    Definitions

 Diffusion - just published for everybody to use

 Dissemination – in addition, actively distributed to end
  users

 Implementation – change management, CPD, localization
  of guidelines
       Localizing, adopting, adapting

Why         >    Systematic review or study
What        >     (National) guideline
How         >    (National) guideline
                 Localised guideline
Where       >    Localised guideline
By whom     >    Localised guideline

When        >    Treatment plan/appointm.
                                           Seamless care
        Patient or information




                                                       Care pathway
Helathy n=?
At risk n=?
Acutely ill n=?
Chronically ill n=?                                                                           Functional level
                                                                                              Clinical picture
                                                                                              Satisfaction
                                    PHC




                                                        Rad
                                                        Lab
                                               Ped
                                          ER



                                                                                              Costs
                                                                                                Clinical
                                                                                                Value
                                               Health center                                    Compass
                      Social work              Hospital
                                                               Social Insurance Institution
                                           Private
                  Seamless Care

  Existing Clinical Practice Guidelines
  Problems / need detected at the grass roots level




              Syöte                    Palvelu /
                                       tuote
Toimittaja               Process                       Asiakas

             ( Input)                   ( Output )
  Currently: need for change? problems?




               tuska



        totu           tule
        us             vais   taika
turva                  uus
                tek
                o




                työ
                   Localize
 Clinicians (opinion leader)
 Users (health care professionals)
 Based on the available evidence (national
  guidelines)
 Agree on process of care
 Measures! Audit criteria!
 Concise, electronic, linked to essential
  knowledge
 In practice?



                                                                   Multia


                                      Virrat             Keuruu
                          Kihniö

                   Parkano
                                                    Vilppula
                                                          Mänttä
                                               Ruovesi                Jämsä
                                   Kuru
                     Ikaalinen
                                                     Juupajoki        Jämsänkoski
                             Viljakkala

         Lavia         Hämeenkyrö         Tampere Längelmäki
                                               Orivesi
             Suodenniemi        Ylöjärvi                                Kuhmoinen
                   Mouhijärvi
           Kiikoinen
                             Nokia                 Kuhmalahti
                                PirkkalaKangasala
                                               Sahalahti
             ÄetsäVammala                                Luopioinen
                                   Lempäälä        Pälkäne
                              Vesilahti
                                  ViialaValkeakoski
                                       Toijala
                    Punkalaidun Kylmäkoski
                              Urjala
Asthma
          Building shared vision


                                                                    Co-creating


                                                  Consulting

                                Testing

                Selling


Telling

                               Degree of active involvement

           Senge P, Kleiner A, Roberts C, Ross R, Smith B.
           The fifth discipline fieldbook. Nicholas Brealey Publishing, London 1996.
Free access! Also patients
495
           Electronic decision aids
Based on the diagnosis that the physician makes /codes
Electronic Patient Record



If ATC = ’J01C’
   then show reminder ’Allergic to penicillin!’

...direct links to the appropriate part of the practice guideline
...pop up cautions, alerts etc. are being formulated

                       MD Ilkka Kunnamo &al, Evidence Based Medicine
                       Guidelines, Duodecim
      Department of General Practice

 NHS joint working party report 2004:
   ’...joint approaches at the local level...setting
      up joint clinical directorates that span
      primary and secondary care’

   ’..routine joint review of clinical
      incidents...progress with initiatives such as
      ...the use of national guidelines and agreed
      local evidence-based formularies’
        Guidelines to seamless care

 An existing gl
 A problem in coordination of care (betweeen PHC and
  secondary care)
 Involve relevant clinicians, form a working group
 Document current practice
 Agree on coordination, document
 Electronic publication
 CPD, education, learning
 Regular update
  Sanity and management guidelines.
           JO Warner. PAI 2001

sane - carefully assimilates all evidence
 and then acts on the basis of that
 evidence
insane - ignores all the evidence and says
 and does what is in his / her head
unsane - an attempt to at least consider
 the evidence, but then only to accept the
 evidence that is concordant with what is
 in the individual’s head. ----

				
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