Transcript Toiminnaliset ja taloudelliset tavoitteet vuonna 2002

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
Values
Practical applications:
Care pathways, training
programmes
Resources
Evidence
Health technology
assessment
Evidence
Based
Health
Care
Clinical guideline
Systematic
review
Systematic organisation of information
Primary
clinical
research
Epidemiologic data
Economic
evaluations
Study
Study
Primary
laboratory
research
Other
primary
research
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
Dutch Association of Comprehensive Cancer Centres, NL
Dutch College of General Practitioners, NL
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
AGREE Collaboration, INT
World Health Organisation Geneva WHO, INT
Membership
April 2003
www.g-i-n.net
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
What
How
>
>
>
Where
By whom
>
>
Systematic review or study
(National) guideline
(National) guideline
Localised guideline
Localised guideline
Localised guideline
When
>
Treatment plan/appointm.
Seamless care
Patient or information
Care pathway
Social work
Rad
Lab
Ped
ER
PHC
Helathy n=?
At risk n=?
Acutely ill n=?
Chronically ill n=?
Health center
Hospital
Social Insurance Institution
Private
Functional level
Clinical picture
Satisfaction
Costs
Clinical
Value
Compass
Seamless Care
 Existing Clinical Practice Guidelines
 Problems / need detected at the grass roots level
Syöte
Process
Toimittaja
( Input)
Palvelu /
tuote
( Output )
Asiakas
Currently: need for change? problems?
tuska
totu
us
tule
vais
uus
turva
tek
o
työ
taika
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
Kihniö
Virrat
Parkano
Keuruu
Vilppula
Mänttä
Ruovesi
Kuru
Ikaalinen
Viljakkala
Juupajoki
Asthma
Jämsänkoski
Längelmäki
Tampere
Orivesi
Lavia
Hämeenkyrö
Ylöjärvi
Suodenniemi
Mouhijärvi
Kiikoinen
ÄetsäVammala
Jämsä
Kuhmalahti
Nokia
Sahalahti
PirkkalaKangasala
Lempäälä
Vesilahti
Luopioinen
Pälkäne
ViialaValkeakoski
Toijala
Punkalaidun Kylmäkoski
Urjala
Kuhmoinen
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. ----