Agency for Quality in Medicine AQu Med Joint

Agency for Quality in Medicine (AQu. Med) Joint Institution of the GMA and NASHIP Guidelines in Germany C. Thomeczek 2 nd ENQual workshop Helsinki, 2. /3. April 2004 www. azq. de

The German CPG Story Part 1: ASMS CPG-Programme 1994 The High Advisory Council for the Concerted Action in Health Care recommends CPGs to be developed by the Scientific Medical Societies 1995 The Association of the Scientific Medical Societies (ASMS) inaugurates its CPG programme 12/97 320 National ASMS CPGs are available via WWW 3/99 718 CPGs via WWW 10/99 988 CPGs via WWW www. azq. de

Key Problems of the ASMS CPG Programme 1. less than 10 % of ASMS-CPGs mention recommendations' evidences 2. most of them contain no information regarding the CPGs‘ udevelopment process usponsorship / accounbtability uimplementation 3. cost-benefit-questions are explicitly excluded as topic from the ASMS programme 4. Differing guidelines on relevant topics www. azq. de

The German CPG Story – Part 2: GMA/NASHIP CPG-Quality Programme (1) 4 -10/96 2 -3/97 4 -12/97 Development of the German Guideline for CPGs A plan of action for a German Guideline Clearinghouse (GGC) is recommended to GMA and NASHIP Development of GGC-Tools è CPG Critical Appraisal Checklist è CPG Critical Appraisal Reports è GERGIS (German GCP Information WWW Service) www. azq. de

The German CPG Story –Part 2: GMA/NASHIP CPG-Quality Programme (2) 1/98 GMA and NASHIP commission AQi. M to operate the GGC 3/98 GERGIS is available via WWW 4/98 German Cochrane Centre and AQi. M publish 1 st CPGCritical Appraisal Report (Asthma bronchiale) 5/98 GMA and NASHIP offers ASMS, German Hospital Federation (GHF), National Association of Statutory Sickness Funds (NASSF) partnership in the GGC 1/99 GHF and NASSF accept GGC partnership 6/983/99 1/02 ASMS member societies ask for cooperation in GGC Federal Pension Funds became Members in GGC www. azq. de

Combined Actions of GGC · · Priorisation of national CPG programmes · · Evaluation of CPG programmes Critical appraisal of CPGs Quality promotion of CPGs Implementing national CPGs via Quality Circles (“Peer Review Group”) of SHI Physicians Support of EB-patient information services www. azq. de

Legal Regulations regarding CPG-Implementation §§ 137 f SGB V (1. 1. 2000, rev. 1. 1. 2004) 7 • Coordination Council (Joint Federal Council) advises the Mo. H regarding criteria for disease management programs (voluntarilly for patients) • Criteria have to recognise state of the art health care as well as evidence based guidelines…. . (the best avaible evidence) www. azq. de

National Program for Guide. Lines of the GMA NPL- Background • initiated by the implementation of DMP in § 137 f SGB V GMA initiated a National Program for Guidelines (105. Physician Council 2002) • Contract between GMA, NASHIP, ASMS for joint execution of program (25. 9. 2003) www. azq. de

Status quo in Germany (1. 4. 2004) • GGC operated by GMA, NASHIP, GHF, NASSF and FPF • • NPL operated by GMA, NASHIP and ASMS Federal Law Code (SGB) incoporates critical apraisal of CPG and recommandation for DMP 9 www. azq. de

Implementation of Evidence-based Information How to Overcome Barriers ? Evidence-based Information (Guidelines, HTA-Reports, Cochrane-Reports etc) Knowledge ? 10 ? ? GAP In- and Out-Patient Care, Health Professionals, Patients, Health Administration, Politicians Practice G. Antes, German Cochrane Center www. azq. de

Barriers against use of guidelines 1. Mandatory top-down implement. • CPGs should …not simply be imposed on professionals by hospital management or third party payers. • That would result in a standardisation of care that leaves insufficient room to do justice to the needs of each individual patient. • Neither are guidelines a simple tool for allocating scarce resources at the population level. Council of Europe ( 2001) DEVELOPING A METHOLOLOGY FOR DRAWING UP GUIDELINES ON BEST MEDICAL PRACTICES – WWW. COE. INT 11 www. azq. de

To overcome barriers against use of guidelines: 1. Participation of target groups in CPG develop. People involved in guideline development • credible organisation responsible for guideline development • target users involved in guideline development (‘ownership’) • balanced multidisciplinary guideline development group • patient involvement Council of Europe ( 2001) DEVELOPING A METHOLOLOGY FOR DRAWING UP GUIDELINES ON BEST MEDICAL PRACTICES – WWW. COE. INT Grol, Cluzeau, Burgers (2003 ) Br J Cancer 12 www. azq. de

Barriers against use of guidelines 2. Uncertainties regarding legal status of CPGs • Since CPGs are not issued by legislative bodies, they are not legal rules. • However, they may have or acquire legal significance, for instance when they are incorporated into binding rules. • The courts will not automatically equate compliance with CPGs with good medical practice. • Mere deviation from a guideline is unlikely to be considered as negligent. Council of Europe ( 2001) DEVELOPING A METHOLOLOGY FOR DRAWING UP GUIDELINES ON BEST MEDICAL PRACTICES – WWW. COE. INT 13 www. azq. de

To overcome barriers against use of guidelines: 2. Clarify legal conditions of guidelines • Both health professionals and patients need to be aware of the legal implications of adhering to or not following guidelines. • As the role of guidelines in legal proceedings differs from country to country, it is essential that guideline programmes clarify the legal conditions of implementing CPGs in general to their potential users. Council of Europe ( 2001) DEVELOPING A METHOLOLOGY FOR DRAWING UP GUIDELINES ON BEST MEDICAL PRACTICES – WWW. COE. INT 14 www. azq. de

Barriers against use of guidelines strategy • 3. Lack of dissemination / implement. Results from many controlled trials and systematic reviews show that efforts to implement guidelines are often not very successful. • At best, small to moderate improvements in the care process have been found, whereas the impact on patient outcomes has often not been studied or proved to be absent. • Issues of implementation are seldom addressed in the development of guidelines. Grol, Cluzeau, Burgers (2003 ) Br J Cancer 15 www. azq. de

To overcome barriers against use of guidelines: 3. User-oriented, effective implementation • production of different formats of the guideline, including patient versions, and tools for applications • use of Internet • multiple implementation strategies • review criteria, indicators for assessing the use of guidelines Council of Europe ( 2001) DEVELOPING A METHOLOLOGY FOR DRAWING UP GUIDELINES ON BEST MEDICAL PRACTICES – WWW. COE. INT Grol, Cluzeau, Burgers (2003 ) Br J Cancer 16 www. azq. de

Guideline Implementation Key Elements (1) • Guidelines must become an essential element in the undergraduate and clinical training of health care professionals as well as in the continuing professional development of health care teams. 17 Council of Europe: Rec 13, 2001 www. azq. de

Guideline Implementation Key Elements (2) • Systematic approach to managing the quality of health care based upon CPGs is essential. • Use various dissemination and implementation strategies in combinations. • Consider professional, organisational, financial, regulatory incentives and disincentives. • Consider barriers and facilitators of CPG use at both national and local levels (tailored implementation). 18 Council of Europe: Rec 13, 2001 www. azq. de

Effectiveness of Implem. Interventions Effectiveness Type Little or No 19 • Educational materials only • Educational lectures Variable • • Audit and feedback Local opinion leaders Local consensus process Patient-mediated interventions Effective • • Educational outreach visits Reminders Interactive educat. meetings Multifaceted interventions www. azq. de

Factors for Success of CPGs Effective Dissemination and Implementation • Funding must be considered. The source of support must be transparent. • CPGs should target multiple audiences (professionals, patients, and policy makers) and be available in suitable formats for different groups. • CPG clearinghouses facilitate the accessibility of CPGs. 20 Council of Europe: Rec 13, 2001 www. azq. de

"Modules" for CPG Implement. in Primary Care (Germ. Ass. PC Phys. ) • Long version • Short version (leaflet / vademecum) • Doctor‘s Aid version • Patient version • Electronic decision support system

Implementation Aid : Electronic –CPG-based Decision Support – f. e. PRODIGY – www. prodigy. nhs. uk - www. azq. de

Implem. of evid. based health care: National level (out- and in-hospital care ) Tool: Disease Management Programmes www. azq. de German Guideline Clearinghouse 2002

Disease Management in Germany Goal: Effective Chronic Illness Care (Diabetes, CHD, Asthma, COLD, Breast Cancer) Self-management support: to help patients / families cope with the challenges of living with and managing chronic illness. Patient support: goes beyond patient education and information; it equips patients with skills in managing their conditions Decision support to practitioners: includes the effective implementation of evidence-based guidelines Delivery system: includes well-prepared teams able to efficiently coordinate tasks and utilize key clinical data Clinical information system: collects information about important elements of care and makes that information available to health care team members. 24 www. azq. de

1 / 2000 Quality Improvement: Example Diabetes Median RR-Levels Typ 2 Diabetes 2000 -2001 (Saxony) 4 / 2001 www. azq. de

Na izsledkih temelječe smernice. . . Implem. of evid. based health care: Local level (hospital) Tool: Guideline based care pathways The multidisciplinary team: §Medicine §Nursing §Allied health professionals §Health service managers §Patients • dileme Clinical practice guideline • splošne opredelitve vs. konkretna navodila • zagotavljanje potrebnih virov • racionalizacija dela Local knowledge about care needs, support services, etc. • oblikovanje lastne metodologije Care Care pathway 1 pathway 2 pathway 3 pathway 4 pathway 5 • izvirnost • temeljni koncept - prilagoditev obstoječih smernic Patient’s journey of care Zlatko Fras ( 2003 ) National Clinical Practice Guidelines Project in Slovenia, Europ. Conference „Information and Quality in Health Care“, Krakow, 9 April 2003 www. azq. de 26

Implem. of evid. based health care: Regional level (outpatient care) - Tools: Find the guidelines Compare CPGs’ contents Look at the gaps Develop Recommendations Topic Prioritisation Appraise quality Analyze applicability Look at the sources Do peer review Regional guidelines based on national CPGs + + CPD in „Quality Circles“ www. azq. de

Pharmacotherapeutic Circles Guideline group moderators Pharmacotherapeutic Circles data Sickness Funds‘ Prescription Data Base www. azq. de

Implem. of regional guidelines via quality circles: Results – State of Hesse • PTC GPs deceased their costs by 2%, whereas drug costs for all physicians in Hessen rose about 10 % • Combination of education, current feedback mechanisms and printed media seems to be an effective method to optimise quality of care • easy adoption of the guidelines Topics: Diabetes, CHD, Hypertension, Astma, COLD, Dyspepsia / Ulcus 29 www. azq. de

Factors for Success of CPG Implementation Evaluation of Guidelines’ Impact • Well-planned monitoring of guideline effects is essential, and especially the impact of guidelines on health outcomes needs further development and evaluation. • Guidelines can include a list of essential indicators that can be used for evaluating the results of guideline implementation. 30 Council of Europe: Rec 13, 2001 www. azq. de