Electronic decision support system demonstrations

2ND G-I-N CONFERENCE 2004
What sources of information are GPs using for prescribing? Speaker: Bruce Arroll, University of Auckland, New Zealand Additional authors: F Goodyear-Smith, D Patrick, J Harrison and N Kerse.; University of Auckland, (This study was funded by the Ministry of Health, but the opinions are those of the authors.) The general practitioners information resources and prescribing decisions project was undertaken 1. to establish sources GPs use to inform themselves on prescribing decisions. 2. to describe how GPs keep their information up to date. 3. to establish what other factors influence GPs prescribing decisions. A random national sample of 200 General Practitioners within New Zealand was drawn from MediMedia, Initial contact was made with a GP via fax, sending a cover letter and Participant Information Sheet (PIS). The actual interview was undertaken by a non clinical interviewer using Computer Assisted Telephone Interviewing (CATI) techniques. Data was collected from 117 GPs throughout New Zealand. The most commonly used source of prescribing information was the MIMs/NewEthicals drug information book and most GPs felt this was very useful. It was the most commonly used source for drug dosage, drug interaction, and adverse reactions. Other sources were accessed for information about complex prescribing situations such as hepatic impairment and use of medications in pregnancy. Internet sources of prescribing were used by about half of the general practitioners asked. When used they were reasonably frequently utilised People sources of prescribing information included pharmacists, GP colleagues, hospital- based and private specialists. Pharmacists were used on a weekly and monthly basis for advice and felt to be of high value. GP colleagues were also in the main, accessed on a weekly basis and felt to be very useful. Forty two percent of GPs without broadband in their office were considered to be recommended practice (best practice) prescribers and 58% of GPs with broadband were considered other prescribers. For finding information on Chloroquine resistant malaria 46% used Text sources, 22% used websites, 20% used Govt agencies and 11% used colleague contacts. MIMs is a commonly used source but needs broadening to include more information on renal/liver dysfunction etc. Prescribers following recommended practice were more likely to have broadband internet available. Information about Malaria and other travel issues is probably best dealt with using internet sites and broadband would help in this aspect. Encouraging GPs to use the free British National Formulary could also facilitate quality practice. Health for kids asthma management: adapting the best available guidelines to ensure the best possible care Speaker: Tari Turner, Centre for Clinical Effectiveness, Monash Institute of Health Services Research, ‘Health for Kids in the South East’ is a Victorian Government funded project designed to improve health care for children through best practice and partnerships. A major aspect of the project is the development of evidence-based practice guidelines for common conditions. The aim was to pilot an evidence-based process for guideline development by adapting existing high quality asthma guidelines for local use by a tertiary paediatric hospital, local GPs and community We searched for existing evidence for developing evidence-based guidelines and distilled an evidence-based process for guideline development. We formed a multidisciplinary guideline development group (GDG) which included hospital staff, consumers and general practitioners. Existing guidelines were identified and appraised, then adapted to create a locally appropriate evidence-based practice guideline for the management of asthma in children. We identified two guidelines, the British Thoracic Society Guideline on the Management of Asthma and the Royal Children’s Hospital Melbourne Asthma Best Practice Guidelines, as representing the best in evidence-based management and the best in local consensus management of asthma, respectively. Adaptation involved further literature searches, changes to medications and dosing to reflect differing availability of drugs in Australia, removal of sections pertaining only to adult asthma, and changes of emphasis in consensus based recommendations. Although the changes to the content (and particularly the recommendations) were relatively minor, the GDG made substantial changes to the format and language to reflect local practice. Adapting existing high quality evidence-based guidelines is an appropriate, efficient way of creating local guidelines. Adaptation may involve substantial changes to layout and language, even if few changes are made to the recommendations of the existing guidelines. Quality in allied health care: where is the place for guidelines? Speaker: Saravana Kumar, Centre for Allied Health Evidence, University of South Australia, Australia The issue of quality has been of great concern in the health care system as we continue to witness dramatic changes in the structure and delivery of care. Unlike, the medical profession, the ‘quality movement’ in allied health is in its infancy. Allied health professions, including Physiotherapy, routinely are now faced with issues of accountability and justification of care as part of the quality service delivery. As part of this process, increasingly, all stakeholders of allied health (providers, patients, and funders) are relying on evidence-based practice and clinical guidelines to help guide the process of quality service delivery. 2nd Guidelines International Network Conference, 1–3 November 2004 Usable guidelines: supporting the diversity of general practice Speaker: Elizabeth Deveny, Therapeutic Guidelines Limited, Australia Prescribing is one of the research domains where most work has been undertaken on developing clinical decision support software. It is also one of the areas where Australian General Practitioners (GPs) have been most active in computerising their clinical work. The practice of prescribing, with its lists of drugs and the possibilities of events such as drug–drug interactions offers opportunities for utilising computers. More generally, evidence-based approaches to practice encourage clinicians to access current clinical evidence in order to provide the best quality of care. Quality Use of Medicines initiatives, medical informatics literature and many organisations concerned with ‘quality of health care’ regularly argue that electronic decision support, based on well-evidenced clinical practice guidelines (CPGs) and embedded in clinicians’ computers, will improve the quality and appropriateness of prescribing. This improvement is, in turn, claimed to result in better patient outcomes, in particular by promoting best practice and reducing adverse events. The overall aim of the research project was to identify how clinicians determine their needs for information when making clinical decisions. It explored whether clinicians needed (and wanted) technological, or other, assistance with decision-making. In doing so, it also paid particular attention to the attitudes of clinicians towards computer use during consultations. This paper describes some computer interactions between GPs during consultations. It uses transcript and observational data from GP interviews and observations to re-construct computer-clinician interactions with CPGs. In doing so, it illustrates how translating guidelines into an electronic format may shape clinical practice, as well as GP-patient interactions, during consultations. Evidence-based information for health practitioners: dilemmas and solutions from an Australian perspective Speaker: Karen Luxford, on behalf of Katherine Vaughan, National Breast Cancer Centre (NBCC), Additional Authors: Alison Evans; Karen Luxford; Elmer Villanueva; and Helen Zorbas The NBCC has been a leader in Australian Clinical Practice Guidelines (CPGs), developing and implementing nine comprehensive sets of breast and ovarian cancer-related CPGs since its establishment in 1995. However, as experienced by other CPG developers, development and updating of CPGs has been slow and resource intensive, each taking about three years to complete, including peer-review and endorsement by the Australian government. These comprehensive, paper- based CPGs quickly become out-of-date in areas with rapidly emerging evidence. The NBCC shares challenges faced by other information providers in supplying stakeholders with up-to-date evidence- based information in a timely and cost-effective manner. The aim was to explore approaches to ensuring Australian health practitioners are kept up-to-date about evidence impacting on clinical practice in breast and ovarian cancer within budgetary Approaches employed by local and international organisations to develop, update and disseminate evidence-based information were examined. These widely varying approaches were used to inform an NBCC strategy for maintaining the currency of evidence-based information for health practitioners. 2nd Guidelines International Network Conference, 1–3 November 2004 As no single approach appeared to be more effective or used more frequently than any other, the NBCC developed a strategy to pilot a range of approaches, including: • a move from complete, paper- based sets of CPGs to searchable, topic-specific web-based CPGs • prioritisation of topics for systematic ongoing surveillance • alternative methods of CPG endorsement • alternative avenues for publishing CPG updates, such as supplements to clinical journals and the NBCC website • dissemination of key emerging clinical evidence directly to health practitioners via e-alerts and fax- New approaches are required to ensure evidence-based information is developed and updated in a timely manner within budgetary constraints. Ongoing lessons learned will have broad implications for CPG development, dissemination and implementation. An international survey of guideline developers' patient involvement methodologies. Speaker: Sara Twaddle, on behalf of Joanne Topalian; SIGN, United Kingdom Additional Author: Claudia Pagliari, University of Edinburgh, United Kingdom In March 2002, the first author performed an email survey of 15 members of the AGREE 1) to establish which of the organisations were involving patients, carers or patient representatives in 2) to assess what techniques were employed by those organisations that did involve patients, carers 3) to find out what plans these organisations had for involving patients, carers and/or patients' Eight responses were received and a very mixed picture of international patient involvement in guideline development emerged. Five of the respondents involved patients or carers or patients' representatives in their guideline development processes. The level of involvement varied between those that included such representatives as members of guideline groups (three organisations) to those that included patient organisations when inviting comments on draft guidelines. 2.5 years have passed since this small-scale survey. Patient involvement in all aspects of health care continues to be a dominant policy theme in many parts of the world yet there is little consensus on appropriate methods of consumer inclusion in guideline development. The emergence of the GIN network represents an ideal opportunity to build upon the above pilot study to explore the prevalence and nature of patient involvement practices in member states. A mixed format survey will explore the ways in which patients are identified, recruited, trained and utilised in the process of guideline development and examine common barriers and facilitators to consumer involvement. The objective was to establish a base line picture of the nature of patient involvement activities in clinical guideline development across the world. This should facilitate shared learning between member organisations, reduce duplication of effort, guide best practice and aid the development of an agreed methodology for patient involvement 2nd Guidelines International Network Conference, 1–3 November 2004 The survey instrument will be developed and piloted on five international guideline development colleagues. Following any amendments, it will be distributed to the GIN Coordinator who will email it directly to the Lead at each of the member organisations. The anonymised results and recommendations based on them will be summarised and published on the GIN and SIGN websites and the research will be published in the scientific literature. A workshop for GIN members to explore the implications of the results will be held and this may be followed by a further exercise to develop consensus-based guidelines on patient involvement. We ask that the members of GIN please assist us by responding swiftly to the email survey, due for Ibero-American guidelines: useful resource or unnecessary workload in the German Guideline Clearinghouse (GGC) process? Speaker: Christian Thomeczek, Heinrich-Heine University, Gernany Additonal Authors: Elizabeth Bandeira-Echtler, O Weingart; B Richter, H Kirchner, C Thomeczek and G Ollenschläger; Heinrich-Heine University, Germany The GGC was established at the Agency for Quality in Medicine in 1999 in order to assure and improve the quality of clinical practice guidelines. GGC’s evaluation focuses on the English and German languages (EGL). Little is known about the quality and methodology of guidelines being established in other regions, such as the Ibero-American language (IAL) area. The objective was to find out whether IAL guidelines should be included in future GGC evidence- An adapted GGC systematic literature search published between 1990 and 2003 was performed in medical databases (Medline, LILACS), special guideline databases (leitlinien.de, ngc.gov, g-i-n.net) and the Internet (Google). Inclusion criteria: Diabetes mellitus type 2; Spanish or Portuguese language; newest version of guideline. The methodological appraisal was performed by using the GGC checklist (version 2000) comparing IAL with EGL guidelines, the latter being appraised in the 730 IAL references were tracked down. According to inclusion criteria 10 IAL guidelines were compared to 16 EGL guidelines. Main outcomes: The mean methodology scores concerning guideline development, content, practicability and total sum for EGL guidelines did not show statistically significant differences compared to IAL guidelines. Description of selection methods for identification of evidence was reported in 19% of EGL and 40% of IAL guidelines. No relevant methodological differences could be detected between IAL and EGL type 2 diabetes mellitus guidelines. It appears to be useful for future GGC projects to include guidelines from the IAL area. A pilot study should be initiated to investigate the influence of the inclusion of IAL guidelines on the quality and results of the GGC practice. Theoretical socio-cultural differences could be elucidated 2nd Guidelines International Network Conference, 1–3 November 2004

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