What changes when guidelines are updated?

Transcription

1 What changes when guidelines are updated? Analysis of Chronic Respiratory Disease Guideline Updates from Liat Fishman, Susanne Weinbrenner, Günter Ollenschläger German Agency for Quality in Medicine ÄZQ, Berlin, Germany Chicago, August 27,

2 Background and Purpose 2 The Problem: Keeping (our) CPGs up to date National Disease Management Guidelines: 1-4 years for development Just published already outdated?! We need to know: - when to update - how to update 2

3 Where to start? 3 Let s see what other guideline groups did Asthma and COPD 3 comprehensive guidelines per topic Systematically developed, evidence- and consensusbased Update methodology should be more or less clear All updates published from 2000 to

4 Analysed guidelines 4 Guideline abbreviation Asthma Reference version (t0) Updates BTS/SIGN (UK) , 2005, 2007, 2008, 2009 GINA (Int.) , 2004, 2005, 2006, 2007, 2008, 2009 NAEPP/NHLBI (USA) , 2007 COPD CTS (CA) GOLD (Int.) , 2004, 2005, 2006, 2007, 2008, 2009 NICE (UK) Legend: block letters = full revision; normal lettering = Partial update 4

5 What did we look for? 5 Why were the guidelines updated? Which methods were used? Are changes transparent? Which changes? Which topics most frequently affected? Consistency of results across guidelines? 5

6 Update methodology 6 Guideline abbreviation Asthma BTS/SIGN (UK) GINA (Int.) NAEPP/NHLBI (USA) When and what? - yearly - modular - topics chosen by experts - yearly - sensitive literature search - literature monitored (no searches?) - experts decide if partial or full update needed How is relevant literature identified? - key questions for topics - systematic searches - pharmacotherapy searched yearly - abstracts (and possibly full texts) reviewed by experts for impact - partial update: systematic search on selected topics - full update: comprehensive, systematic searches on all topics 6

7 7 Update methodology Guideline abbreviation COPD When and what? How is relevant literature identified? CTS (CA)? Review Panel evaluated all papers published since original version GOLD (Int.) See GINA See GINA NICE (UK) - original lit. searches rerun after 3 years (NICE Guideline Manual 2007) - views of healthcare professionals and patients sought Scope and search questions drafted partial update 7

8 How are changes indicated in guidelines? 8 BTS/SIGN NAEPP/NHLBI 8

9 How are changes indicated in guidelines? cont. 9 GINA and GOLD Full revision 9

10 How are changes indicated in guidelines? cont. 10 NICE 10

11 Types of changes - classification 11 Type Description Example Recommendation before Recommendation after Major In a decision context: > 1 change in therapy goal, strategy or option goal, strategy or option added goal, strategy or option removed Step 2 care options: Nedocromil / cromolyn OR low-dose ICS. Step 2 care options: Preferred: Low-dose ICS. Alternative, but not preferred: Cromolyn OR LTRA change in priorisation Strength or Recommendation added or removed completely Annual influenza vaccinations are recommended for patients with persistent asthma. The Expert Panel recommends that clinicians consider inactivated influenza vaccination for patients who have asthma. Minor +/- precision, change in details e.g. dosage, information added w/out change in meaning Change in LoE (new references confirm rec) Scuba diving is not recommended for patients with COPD. Scuba diving is not generally recommended for patients with COPD. Advise people with queries to seek specialist advice. 11

12 Types of changes - results 12 Asthma guidelines COPD guidelines 12

13 Changes across topics 13 Asthma guidelines COPD guidelines 13

14 14 Discussion - Limitations Classification relevant changes and topics subjective Complex recommendations Open for interpretative meaning GOLD and GINA: few explicit recommendations ( should, recommend ) 14

15 15 Conclusions So... what is the best way to update?? All methods lead to similar results (quantitatively) Consider modular updates depending on research output (e.g. pharmacotherapy more often, diagnosis less often) Users should be able to easily identify changes Idea: designated expert groups for monitoring topics? 15

16 16 Thank you for your attention! Questions and comments are welcome! No conflicts of interest 16