Towards EBCPGs Implementation for Physicians Dr. Yasser S. Amer MBBCh, MPed, MHCI, CPHQ Coordinator, KSUMC-Wide CPG Steering Committee Coordinator, Research & Development, Quality Management Dept. 06/17/2022 1 6 th Residents Professional Development Course College of Medicine, King Saud University
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Towards Evidence-Based Clinical Practice Guidelines Implementation for Physicians at KSUMC
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05/02/2023 1
Towards EBCPGsImplementation
for PhysiciansDr. Yasser S. AmerMBBCh, MPed, MHCI, CPHQ
6th Residents Professional Development CourseCollege of Medicine, King Saud University
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بســـــم الله الرحمـــــن الرحـــــيم
In the name of Allah. Most Gracious, Most Merciful
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Learning objectives• CPG Definitions & concepts• How to scout for EBCPGs?• How to appraise CPGs (standards)?• Develop or adapt CPGs?• CPG implementation?• KSUMC CPG program• How to access and use KSUMC CPGs ?• What is your role as a physician?
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Evidence-Based Medicine (EBM) Movement: Not new!
• 865–925 Al-Razi (Rhazes)1st need for experiments, comparisons in clinical studies
• 981–1037 Ibn Sina (Avicenna)test effect of drugs on humans not animals only
• 1987 David M. Eddy, MD, PhD ‘EB’ in EBCPGs, policies in workshops, manual
• 1992 Gordon Guyatt, MD‘EBM’ term in JAMA
• 1996 David Sackett, MD‘EBM’ definition in BMJ
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The Georg Ebers Papyrus.
Found in Egypt in the 1870s,the Ebers Papyrus contains prescriptions written in hieroglyphics formore than 700 remedies, including this one for an acute asthma attack.From: University of Leipzig
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The EBM Triad
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Definition: (old)
“Systematically developed statements to assist
practitioner and patient decisions about appropriate
health care for specific clinical circumstances”
(IOM 1990) Increasing international interest in the development
& implementation of CPGs!
Clinical Practice Guidelines (CPGs)
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CPGs Definition (New)
“Statements that include Recommendations
intended to optimize patient care that are
informed by a Systematic Review of evidence and
an assessment of the benefits and harms of
alternative care options”Committee on Standards for Developing Trustworthy
CPGs (IOM-AHRQ 2011)
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WhyDo we need CPGs?
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Rationale for CPGs•Worldwide concerns about:- ▫Unexplained variation/ variability in clinical practice
▫Rising healthcare costs
▫Exponential growth of health information• Aim of CPGs:-
To facilitate more consistent, effective and efficient practice and improve health outcomes for patients
Adaptation of CPGsIs the systematic approach to the endorsement
and/or modification of a guideline(s) produced in one cultural and organizational setting for application in a different context. Adaptation may be used as an alternative to de novo guideline development, e.g., for customizing (an) existing guideline(s) to suit the local context.
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Types of CPGsThe Role of CPGs in Health Care Reform (Rosoff AJ 1994)CPGs are basically of two types:-
1. Quality-enhancing CPGs are primarily intended to improve medical outcomes, often by increasing the amount of care given.
2. Cost-reducing CPGs are oriented toward cutting costs, generally, by limiting the amount of care given.
7. Systematic methods for E search8. Selection Criteria of E9. Strengths & Limitations of E10. Methods of Rs formulation 11. Benefits , side effect and risks in Rs12. Evidence Links (Gs of Rs – LoE)13. External Review 14. Update Procedure
DOMAIN 3. RIGOUR OF DEVELOPMENT
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DOMAIN 4. CLARITY OF PRESENTATION
15. Rs are specific 16. Options for management 17. Recommendation identifiable
CPG Implementation“The concrete activities and interventions undertaken to turn policies into desired results“
Guidelines for clinical practice: from development to use. IOM, 1992
CPGs Practice
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Implementation researchis the scientific study of methods to promote the systematic uptake of proven clinical treatments, practices, organizational, and management interventions into routine practice, and hence to improve health.In this context, it includes the study of influences on patient, healthcare professional, and organizational behavior in either healthcare or population settings.http://www.nlm.nih.gov/hsrinfo/implementation_science.html
Implementation scienceIt is the study of methods to promote the integration of research findings and evidence into healthcare policy and practice.It seeks to understand the behavior of healthcare professionals and other stakeholders as a key variable in the sustainable uptake, adoption, and implementation of evidence-based interventions.As a newly emerging field, the definition of implementation science and the type of research it encompasses may vary according [to] setting and sponsor. However, the intent of implementation science and related research is to investigate and address major bottlenecks (e.g. social, behavioral, economic, management) that impede effective implementation, test new approaches to improve health programming, as well as determine a causal relationship between the intervention and its impact.http://www.nlm.nih.gov/hsrinfo/implementation_science.html
Is the purposive distribution of information and intervention materials to a specific public health or clinical practice audience.The intent is to spread information and the associated evidence-based interventions. Research on dissemination addresses how information about health promotion and care interventions is created, packaged, transmitted, and interpreted among a variety of important stakeholder groups.http://www.nlm.nih.gov/hsrinfo/implementation_science.html
CPG ImplementabilitySet of characteristics that PREDICT the relative ease of implementation of CPG recommendations.Implementability is an abstract concept related to several factors, including intrinsic factors that are specific to the CPG itself and under control of the CPG development group and extrinsic factors that are often specific to the intended healthcare settings and context of implementation.
Implementability…….BEFORE implementation
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CPG implementation Strategies (SIGN)
Dissemination Process (print/ e-/website). Local Clinical Champions. Awareness raising/ training activities. Regular M & E (Auditing) (The ‘living’ CPG concept!). Networking and linking with existing projects (e.g. Dept.
Clinical Rounds, CPD/CME activities, Accreditation, etc..). Patients as champions for change.
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CPG implementation Toolsavailable at the point of care (* MR)
Examples1.Clinical Algorithm2. Integrated Care/ Clinical Pathways3.Protocol and/ or Policy & Procedure4.Chart Documentation/ forms (e.g. Physician Order Sets: eSIHI
Intrinsic to CPG:ambiguity – inconsistency - incompleteness
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Barriers (Physician adherence to CPGs)*
I – KNOWLEDGE:-• Lack of familiarity and/or AwarenessII – ATTITUDES:-• Lack of agreement with specific CPGs• Lack of agreement with CPGs in general• Lack of outcome expectancy• Lack of self-efficacy• Lack of motivation/ inertia of previous practice
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Barriers (cont’d)
III – BEHAVIOR:-• External factors (e.g. patient factors, care
system factors)• Internal factors (CPG factors)• Environmental factors
*Enhancing the Use of Clinical Guidelines: A Social Norms PerspectiveThe McDonnell Norms Group 2006
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Individual Positive attitude Learning through small
group interaction
Environmental• Professional
association/society support• Inter-organizational
collaboration networks
Facilitators Organizational• Leadership support• Champions• Team work
collaboration
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KSUMC CPG PROGRAMcurrent status 2015 - 1436
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Clinical Practice Guidelines (CPGs) Program of King Saud University Medical City
23 KSUMC CPGs Subcommittees1. Department of Pediatrics (7)2. Department of Critical Care (3. Department of Psychiatry 4. Primary Care/ Family Medicine Clinics 5. Department of Pharmacy 6. Department of Emergency Medicine 7. Department of Medicine8. Department of Orthopedic Surgery 9. Department of Otorhinolaryngology 10. Department of Ophthalmology 11. Department of Cardiac Sciences/ KFCC 12. Department of Surgery 13. Department of Obstetrics & Gynecology 14. Department of Dermatology 15. Department of Anesthesiology 16. Department of Laboratory Medicine &
Pathology
17. Department of Nursing18. Department of Radiology 19. Health Education Center 20. Department of Rehabilitation Medicine21. Department of Infection Control22. Department of Occupational Health & Safety23. Department of Clinical Nutrition