The 2010 evidence-based guidelines: the process, the challenges

Transcription

1 The 2010 evidence-based guidelines: the process, the challenges Jerry Nolan Co-Chair, ILCOR Royal United Hospital Bath, UK European Society of Cardiology Stockholm 30 Aug 2010

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3 The 2010 guidelines: the process, the challenges Brief history The 2010 Consensus on CPR Science From science to guidelines

4 CPR Guidelines National Academy of Sciences National Research Council ad hoc conference on CPR International Symposium on Emergency Resuscitation, Oslo, Norway AHA Standards and guidelines CPR and ECC 1974, 1980, 1986, 1992.

5 Australian Resuscitation Council

6 International Guidelines st attempt to achieve global, standardised CPR guidelines In reality, consensus not achieved ERC published separate guidelines

7 2005 International Consensus Conference on ECC and CPR Science with Treatment Recommendations 281 experts completed 403 systematic reviews on 276 topics Morley PT. Resuscitation 2005;67: conference participants

8 2005 Consensus on CPR Science Resuscitation 2005;67:

9 2005 CPR Guidelines Resuscitation 2005;67 Suppl 1:S Circulation 2005;112: Suppl IV

10 ILCOR Taskforces for 2010 Advanced Life Support Basic Life Support Paediatric Life Support Neonatal Life Support Acute Coronary Syndromes Education, Implementation & Teams* Overlap Topics*

11 ILCOR Taskforce Format C2010 Two co-chairs Past co-chairs 1-2 representatives from each ILCOR member council Two face-to-face meetings per year Webinars two per month

12 Conflict of Interest Intellectual and/or financial Heavily influences interpretation of data All C2010 participants completed conflict of interest statements on line Shuster M. Resuscitation 2010;81: in press

13 Evidence evaluation process Identifying the questions to ask Formatting the questions (PICO) Evidence evaluation experts 2 worksheet authors per question Levels of evidence Identifying the gaps Worksheets on internet ( Morley PT. Resuscitation 2010;81 in press

14 Formatting the questions (PICO) In post-cardiac arrest patients with ROSC (P), does therapeutic hypothermia (I) compared with usual care (C), improve morbidity or mortality (O)? Morley PT. Resuscitation 2010;81 in press

15 C2010 Levels of Evidence for Studies of Therapeutic Interventions LOE 1: Randomised controlled trials (or metaanalyses of RCTs) LOE 2: Studies using concurrent controls without true randomisation LOE 3: Studies using retrospective controls LOE 4: Studies without a control group LOE 5: Studies not directly related to the specific patient/population (e.g. different patient/ population, animal models, mechanical models etc.) Morley PT. Resuscitation 2009;80:719-21

16 Supporting evidence table A = Return of spontaneous circulation C = Survival to hospital discharge E = Other endpoint B = Survival of event D = Intact neurological survival # = meta-analysis * = overlapping patients

17 International Consensus Conference on ECC and CPR Science with Treatment Recommendations 1-4 th Feb PICO questions 313 delegates from 30 countries Treatment recommendations based on science New ERC and AHA guidelines online 18 th October

18 C2010 Conflict of interest policy

19 Consensus on science statement: example from 2005

20 Treatment recommendation: example from 2005

21 ERC Guideline: 2005 example

22 From science to guidelines Guidelines must take into account: Science Education issues Cost effectiveness Cultural differences?

23 Implementing the guidelines: ERC courses

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25 Problems with the international CPR science review process Time-consuming and expensive Some authors failed to complete worksheets Failure to reach consensus Few data Disagreement on interpretation Late-breaking science Missed topics, e.g., practical issues

26 Solutions? Focus on new data Focus on topics likely to result in change of practice More frequent interim statements No need for large consensus conferences?

27 Evidence-based resuscitation guidelines: summary Comprehensive evidence-based science reviews behind the guidelines 2010 process more complex than 2005! Very few high-level, high-quality studies in resuscitation Some international variation in guidelines is probably inevitable?

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