Country Delegates Workshop March, 2013 Overview of existing breast cancer screening guidelines

Transcription

1 Country Delegates Workshop March, 2013 Overview of existing breast cancer screening guidelines Federici Antonio Ministry of Health- Italy

2 AGENDA THE STUDY (Quality appraisal of of guidelines for breast, colorectal and cervical cancer screening) REMARKS & SUGGESTIONS

3 The mandate: National Plan: strengthening of of governance by by generating knowledge from MoH to to Lazio Region Health-Agency (Giorgi (Giorgi Rossi Rossi team) team) The rationale: quality of of a GL ;; operational use in in the day-by day practice variance of of professional s behaviour and GLs The objective: to to collect SPs guidelines and their quality appraisal.

4 The method literature search of of the major databases & websites (since yr yr 2000; only only Italian or or English; keywords by by the the Editorial Group of of the the Cochrane Collaboration) Guideline quality assessment, using the instrument developed by by the Appraisal AGREE Collaboration of Guidelines for AGREE Research and Evaluation scope and purpose stakeholder involvement DOMAINS rigour of development clarity and presentation Applicability editorial independence

5 Suggestion&remarks Main results: breast Relevant documents identified: breast [33 [33 cervix; colon] Several areas of of disagreement and and /or /or variability Assessable by by AGREE: [19 [19 cervix; colon]

6 Main areas of disagreement (1) Organization Starting age: 40, 45, 50 Stopping age: 69, 74, none Interval: 1 to 3 yy First level test : Two or one projections Use of digital mammography (only since early 2000s) Clinical exam (only 3 ggll) Ultra sounds (only 2 ggll) One or Two readings

7 Main areas of disagreement (2) Assessment and Pathology Criteria for use of FNAB or FNAC Use of VACNB Use of MRI (presurgery ) Surgery (points relevant for diagnostic pathway) Sentinel node in DCIS Cosmetic (simultaneous)

8 Main features (3) Familial Many GGLL refer to specific documents Criteria: Great variability in the definition of intermediate risk and referral to screening or not High agreement for genetic risk

9 breast screening quality appraisal AGREE (1 ) objectives of GGLL scope and purpose clinical question target patients FONCAM 2005 ss Italy 2 3,5 2 EU 2006 gov International 2,5 3,5 3 NHS BSP 2010 gov UK 3,5 3,5 4 GISMa 2006 ss Italy ACP 2007 ss USA SIRM 2004 ss Italy 3,5 3,5 2 RER 2008 gov Italy 1,5 3 1 USPSTF 2009 gov USA 4 4 3,5 ACS ss USA ACR 2008 ss USA 2,5 3 1 ANAES 2000 gov France ISPO 2010 gov Italy 3,5 3,5 4 mean governmental bodies 3,00 3,42 3,25 mean scientific societies 3,33 3,50 2,83 mean all 3,17 3,46 3,04

10 breast screening quality appraisal AGREE (2 ) professionals stakeholder involvement patients GGLL users FONCAM 2005 sci soc Italy 1,5 1 1 EU 2006 gov International NHS BSP 2010 gov UK 3 2 2,5 GISMa 2006 sci soc Italy 4 4 3,5 ACP 2007 sci soc USA SIRM 2004 sci soc Italy 1,5 1 1 RER 2008 gov Italy 3 1 1,5 USPSTF 2009 gov USA 3 2 2,5 ACS sci soc USA 3,5 2,5 2,5 ACR 2008 sci soc USA ANAES 2000 gov France ISPO 2010 gov Italy 4 1,5 3 mean gov 3,17 1,42 2,42 mean sci soc 2,08 1,75 1,67 mean all 2,63 1,58 2,04 pilot with users

11 breast screening quality appraisal AGREE (3 ) systematic review selection criteria rigour of development methods for recommendation s health benefits, risk and side effects link evidence - recommendation s external review updating procedures FONCAM 2005 sci soc Italy ,5 1 1 EU 2006 gov International 2, ,5 3 NHS BSP 2010 gov UK 2,5 2 2,5 3,5 3 2,5 2,5 GISMa 2006 sci soc Italy 2,5 2 2,5 4 3,5 3 1,5 ACP 2007 sci soc USA 3,5 3, ,5 1 1 SIRM 2004 sci soc Italy 2 1,5 2 2,5 2,5 2 1 RER 2008 gov Italy 2 1,5 2 2, USPSTF 2009 gov USA 3,5 2,5 3,5 4 3,5 1 1 ACS sci soc USA 3, , ,5 ACR 2008 sci soc USA , ,5 ANAES 2000 gov France ISPO 2010 gov Italy 3 3 3, ,5 1,5 mean gov 2,92 2,50 2,92 3,17 2,92 2,08 1,67 mean sci soc 2,25 2,00 2,08 2,92 2,83 1,83 1,25 mean all 2,58 2,25 2,50 3,04 2,88 1,96 1,46

12 breast screening quality appraisal AGREE (4 ) recommendation s not ambiguous clarity and presentation options specified recommendation identifiable tools for applicatio n FONCAM 2005 sci soc Italy 3 3,5 3 1,5 EU 2006 gov International 2,5 2,5 1,5 4 NHS BSP 2010 gov UK 3,5 3,5 3,5 3,5 GISMa 2006 sci soc Italy 4 3,5 3,5 2,5 ACP 2007 sci soc USA 3 2 3,5 2 SIRM 2004 sci soc Italy 2, RER 2008 gov Italy 3,5 4 3,5 3,5 USPSTF 2009 gov USA 4 3 3,5 2 ACS sci soc USA 3,5 3,5 3,5 2 ACR 2008 sci soc USA ANAES 2000 gov France ISPO 2010 gov Italy 3,5 2,5 3,5 2 mean gov 3,33 2,92 3,08 2,83 mean sci soc 2,83 2,58 2,92 1,83 mean all 3,08 2,75 3,00 2,33

13 breast screening quality appraisal AGREE (5-6 ) applicability editorial independence barriers discussed costs im plicatio ns identified criteria for audit and monitorin g independence competing interest disclosure FONCAM 2005 sci soc Italy 1 1,5 2,5 3 1,5 EU 2006 gov International ,5 NHS BSP 2010 gov UK 3 2,5 3,5 2,5 1 GISMa 2006 sci soc Italy 3 3 2,5 3 2,5 ACP 2007 sci soc USA 1 1 1,5 3 1 SIRM 2004 sci soc Italy 2 1,5 1,5 2 1 RER 2008 gov Italy 2 2 3,5 3 1 USPSTF 2009 gov USA 2,5 3 2,5 3,5 2,5 ACS sci soc USA ,5 1 ACR 2008 sci soc USA 1,5 1 1,5 1 1 ANAES 2000 gov France ISPO 2010 gov Italy 2 2,5 2 3,5 4 mean gov 2,25 2,17 2,92 3,25 2,00 mean sci soc 1,58 1,50 1,92 2,42 1,33 mean all 1,92 1,83 2,42 2,83 1,67

14 breast screening quality appraisal AGREE total Total total std score FONCAM 2005 sci soc Italy 41 46,6 EU 2006 gov International 58 65,9 NHS BSP 2010 gov UK 63,5 72,2 GISMa 2006 sci soc Italy 69 78,4 ACP 2007 sci soc USA 51,5 58,5 SIRM 2004 sci soc Italy 43,5 49,4 RER 2008 gov Italy 49 55,7 USPSTF 2009 gov USA 64,5 73,3 ACS sci soc USA 61 69,3 ACR 2008 sci soc USA 29,5 33,5 ANAES 2000 gov France 56 63,6 ISPO 2010 gov Italy 66,5 75,6 mean gov 59,58 67,72 mean sci soc 49,25 55,95 mean all 54,42 61,83

15 Suggestion&remarks Main results: breast In USA, most of of the documents are from scientific societies, while in in Europe most are from governmental agencies: two kinds of of health systems produced different guidelines and/or documents reporting recommendations

16 EU cancer screening GLs: appraisal AGREE (1) EU GGLL AGREE score improved from 2006 to 2010: 1) better quality of methodology 2) more consistency between objective and contents, from quality assurance of the single procedure to QA of the whole screening process EU 2006: (breast) EU 2008 (cervical) EU 2010 (colorectal)

17 1. 1. The assessment of of quality can t be be carried out by by a single clinician and the decision making by by a single specialist could be be weak A GL GL must be be a part of of a more complex frame of of managing clinical problems. A good-quality-gl is is a tool tool for for having having standards to to use use in in the the evaluation of of clinical clinical processes, outputs outputs and and outcomes. Therefore it it should should be be a part part of of a more more complex system system on on improving quality, quality, besides besides audit, audit, training and and so so on. on. But But the the frame frame of of governance is is actually different if ifwe are are considering the the management responsibility at at local local or or regional level. level. Even Even different if if we we are are at at the the policy policy making making level. level Not (only) wishing for for the actual use of of a GL: it it is is the case of of managing the issue of of knowledge in in a broader scenario: that of of governance

18 The governance Stewardship: subfunctions Formulating strategic policy framework Generation of of intelligence Ensuring tools for implementation Ensuring a fit fit between policy objectives and organizational structure and culture; Building coalitions/building partnerships Ensuring accountability Travis P,. Towards better stewardship: concepts and critical issues. Geneva, WHO, Novinskey CM,. Stewardship and cancer screening programs in Italy. IJPH - Year 9, Volume 8, Number 2, 2011

19 Having a guideline makes difference only if if it s a tool in the tool-box of governance. For example, to finance Regions (or health services) Adherence= % of of target population actually screened (3 (3 screening as as a whole) :: already implemented since % Early stage cancer (breast cancer screening) detected in in the rounds following the first [stage II+ II+ 25%]: under evaluation for for feasibility

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21 Included GGLL Author Acronym Year Country AGREE Agence Nationale d Accréditation et d Evaluation en Santé [44] ANAES 2000 France Yes Royal College of Surgeons in Ireland [45] RCSI 2000 Ireland Canadian Task Force on Preventive Health Care [46] CTFPHC 2001 Canada American Cancer Society[47-48] ACS International Yes Regione Toscana [22] PNLG 2003 Italy Società Italiana di Radiologia Medica[49] SIRM 2004 Italy Yes Ministero Salute [2] ONS 2005 Italy yes Forza Operativa Nazionale sul Carcinoma Mammario[51] FONCAM 2005 Italy Yes Agence d'évaluation des technologies et des modes d'intervention en santé[50] AETMIS 2006 Canada European Commission[52] EC 2006 EU Yes National Institute for Health and Clinical Excellence[53-54] NICE UK World Health Organization [55] WHO 2006 International American College of Physicians[56] ACP 2007 USA Yes Regione Piemonte[57] CPO 2007 Italy

22 Included GGLL Author Acronym Year Country AGREE Gruppo Italiano Screening Mammografico[58] GISMA 2007 Italy Yes American College of Radiology[59] ACR 2008 USA Yes Associazione Italiana Oncologia Medica[60] AIOM 2008 Italy Institute for Clinical Systems Improvement[61] ICSI 2008 International Regione Emilia-Romagna[62] RER 2008 Italy Yes Australian Institute of Health and Welfare [63] AIHW 2008 Australia Cochrane Database of Systematic Reviews[16] Cochrane 2009 International National Institute for Health and Clinical Excellence[64] NICE 2009 UK Provincia autonoma di Trento[65] Trento 2009 Italy U.S. Preventive Services Task Force[66] USPSTF 2009 USA Yes Regione Toscana [43] ISPO 2010 Italy Yes NHS Breast Screening Programme[67] NHSBSP 2010 UK Yes 32 found 26 selected 12 suitable for AGREE evaluation