An introduction on Evidence-Based Clinical Practice Guidelines in Health Care Organizations Brief on Alexandria Center for EBCPGs in Alexandria University Hospitals, Egypt By Dr. Yasser Sami Abdel Dayem Amer, MBBCh, MS 2013 Special Thanks to Prof Dr Mahmoud Elzalabany Prof Dr Tarek Omar Prof Dr Nabil Dowidar Prof Dr Afaf Gaber

2. Evidence-Based
Clinical Practice Guidelines
(EBCPGs)
For Medical Staff of
Healthcare Organizations (HCOs)
Introduction
By
Dr. Yasser Sami A. Amer, MBBCh, MS
Pediatrician - HC Informatician
EBCPGs Advisor & Trainer
2013

3. Concepts & Definitions

4. Two Different Approaches to Evidence-Based
Practice (EBP)
Clinical Practice Guidelines (CPGs)
•“Top-down” approach
• Tell clinicians how to practice
• Favored by health care systems
Evidence-Based Medicine (EBM)
•“Bottom-up” approach
• Teach clinicians how to find answers
• Favored by medical educators

5. EBM definition
The integration of best research evidence
Clinical
with clinical expertise and patient
values Expertise
Sackett et al 2000
Research Patient
Evidence Preferences

6. What is “EBM” NOT?
• What we have always done !;
(not old hat or just the same old medical practice; as evidenced in wide
practice variation)
• “Cookbook Medicine”!
EBM specifically advocates for individualized application of evidence to patient
care, not forcing patient care to conform to generalized evidence
• Only a cost-cutting trick !;
it is intended to guide practitioners to provide the best, not necessarily the cheapest,
care.
• Only RCTs !;
(Also with best relevant evidence applicable to the situation in
question)
– EBM is tracking down the best external evidence from
scientific research to answer our clinical question(s)…

7. Clinical Practice Guidelines (CPGs)
Definition: (old)
“Systematically developed statements to assist
practitioner and patient decisions about
appropriate health care for specific clinical
circumstances” (Institute of Medicine 1990).
Increasing international interest in the
development and implementation of CPGs.

8. CPGs New Definition
CPGs are “Statements that include
Recommendations intended to optimize
patient care that are informed by a
Systematic Review of evidence and an
assessment of the benefits and harms of
alternative care options”.
Committee on Standards for
Developing Trustworthy CPGs (IOM-
AHRQ)

9. Why do we need guidelines?

10. Rationale for CPGs
• Worldwide concerns about:
▫ Unexplained variations in clinical practice
▫ Rising health care costs
▫ Exponential growth of information
• Aim of Clinical Practice Guidelines:
▫ To facilitate more consistent, effective and
efficient practice and improve health outcomes for
patients

11. Clinical Best
Care GAP Practice

12. Who needs guidelines?

13. • Doctors
• Nurses
• Decision makers
• Patients
• Public

16. CPG Producers:
Specialized Societies: e.g. AAP

17. CPG Producers:
National Agencies
SIGN
Scottish
Intercollegiate
Guidelines Network
www.sign.ac.uk

18. CPG Producers:
National Agencies
NICE
National Institute for
Health & Clinical
Excellence
www.nice.org.uk

19. AHRQ
National Guideline
Clearinghouse
www.guidelines.gov

20. Guidelines
Internationa
l Network
(G-I-N)
www.g-i-n.net

21. PubMed
US National Library of
Medicine
National Institutes of
Health (NIH)

22. Some CPGs are only retrievable by
“Googling” them!

23. How do we react to
guidelines?

24. Develop
Adapt
Adopt
Read
CPGs ?

25. Topic
Team
Content
Search
FOUND NOT FOUND
Appraise Develop
Adopt or Adapt Appraise
Implement
Evaluate impact

27. Adaptation of Clinical Practice
Guidelines
The ADAPTE collaboration is an
international collaboration of CPG researchers, developers and
implementers. Their main aim is to develop and validate a
generic adaptation process that will foster valid and high-quality
adapted guidelines as well as the user’s sense of ownership of
the adapted guideline.
Since 2009 The ADAPTE Collaboration has merged into the Guidelines
International Network (G-I-N) with all its resources to form the G-I-N
Adaptation Working Group

28. Guideline Adaptation
• Is the systematic approach to the endorsement and/or
modification of a guideline(s) produced in one cultural
and organizational setting for application in a different
context. Adaptation may be used as an alternative to
de novo guideline development, e.g., for customizing
(an) existing guideline(s) to suit the local context.
• http://www.adapte.org/

29. ©Copyright ADAPTE 2007

30. Adaptation Phase
We identified 3 main ADAPTE steps:-
Search & Selection of source CPGs
Health Questions (PIPOH)
AGREE II Instrument
Assess source CPGs quality
External Review
(Departmental Consensus)

32. CPG Scope: PIPOH Model
Patient (& disease characteristics)
Intervention(s)
Professionals (Target users)
Outcomes (purpose of the CPGs)
Healthcare settings (& context)
= Health/ Clinical/ Key Questions

33. Evidence Pyramid
Grades of Recommendations
MA
Levels of Evidence
I A
RCT
Cohort
II
Case control
B
Case series
III
Case report
IV Expert opinion C

34. How to assess of the quality of any CPG ?

35. Assess guideline
quality
ADAPTE TOOL 9 AGREE II Instrument
23 items in 6 domains
7 point response scale
Domain scores
Recommendations

36. AGREE II
DOMAINS
Domains
1 Scope & Purpose
2 Stakeholder Involvement
3 Rigour of Development
4 Clarity & Presentation
5 Applicability
6 Editorial Independence

37. Hospital Official CPGs:
Two separate documents
FIRST (Clinicians’ Version)
• Accessible from ALL points-of-care
for the hospital staff:
• Details of evidence-based
recommendations for management
(with only references to the other
document)

38. SECOND:
(Methodologist’s Version) ;
• Accessible from Libraries
of e.g. Department,
College of Medicine, CPG
Committee, QMD,
Authorship group,…etc.
(Reference for Replication &
Documentation)
• Detailed description of the
CPG Adaptation process
with ALL relevant data.

39. Dissemination & Implementation
Nothing could be more
frustrating than producing
a CPG that is then ignored
by not being disseminated
nor implemented

40. Dissemination of CPGs
• Full CPGs documents published on
websites - integrated into HCO’s Health Information
System (HIS) & Electronic Medical Records (EMRs)
• Implementation tools will also be published:
examples for choice:-
▫ Quick Reference Guide (Summary Key Rs)
▫ Clinical Algorithms (decision tree)
▫ Clinical pathways (Integrated care pathways)
▫ Patient Information (Education Guide)
▫ Gantt chart for dissemination & Implementation
▫ Audit and Research Rs.

41. Implementing Guidelines
• If CPGs are to have a positive impact on
patient care outcomes they must be
implemented and incorporated into everyday
clinical practice
• The identification of any barriers to
implementation, and strategies for
overcoming them, will form an essential
part of discussions at CPGs
Subcommittee/ Adaptation Group
meetings

42. Launching of
Clinical Practice Guidelines
Taskforce members
TEAM WORK

44. 2006
1999
2004

46. Alexandria University Hospitals
Healthcare Quality Directorate
Center for Evidence-Based Clinical Practice Guidelines
(AUH – HCQD, CEBCPGs)
(Founded Nov. 2008)
Member of Guidelines International Network (G-I-N)
(Since May 2009)

49. Founding Members 2008
• Prof. Dr. Mahmoud Elzalabany
• Prof. Dr. Tarek Omar
• Prof. Dr. Afaf Ibrahim
• Prof. Dr. Nabil Dowidar
• Dr. Yasser S. Amer
• Dr. Hossam Ashour
• Eng. Ahmed Mourady

50. G-I-N Annual Report 2009
EGYPT (EG)

51. First Workshop in Egypt: Adaptation of CPGs
2009 (AFM-GIN-ADAPTE)

52. *12 M.Sc. Theses plus 1 Ph.D. thesis to produce 13 Adapted EBCPGs
4 Finalized Adapted CPGs by CEBCPGs, HCQD-AUHs through MSc
Theses (till 3/2012) in PEDIATRICS DEPT.:
1- Treatment of Acute Childhood Asthma in ER - AUCH: Dr. Yasser Sami Amer
(Finalized, Approved , Disseminated & Implemented).
2- Treatment of Positioning & Attachment Breast Feeding Problems in BFCC - AUCH:
Dr. Georgina Ramsis (Finalized & Approved).
3- Triage and Acuity Scale in A & E Dept., AMUH: Dr. Mary Christeen Nabiel Sharobeem
(Finalized, Approved & Disseminated ) – the only thesis outside the Pediatrics Dept.
4- Treatment of HIE in Neonates in NICU: Dr. Walid Gamal AbdelKhaliq
(Finalized & Approved).
5- Treatment of ADHD in children in AUCH: Dr. Mariana Iskander Amin
9 Adapted CPGs in progress by Pediatrics Dept. & CEBCPGs, HCQD-AUHs
through MSc/PhD Theses (till 8/2012):
1. Diagnosis of acute attack of seizures in AUCH: Dr. Soheir Farouk AbdelSalam (Set
Up Phase).
2. Treatment of acute attack of seizures in AUCH : Dr. Islam Yousry A.Moneium (Set Up
Phase).
3. Management of Epilepsy in children in AUCH: Dr. Shimaa Anwar (Set Up Phase)
4. Treatment of Childhood Autism in AUCH: Dr. Farioz Ibrahim (Set Up Phase).
5. Management of Acute Bacterial Meningitis in AUCH: Dr Mariam Adly (Set Up Phase).
6. Treatment of Chronic Asthma in AUCH: Dr. Reem Galal Ghazal (Set Up Phase).
7. Treatment of Community Acquired Pneumonia in AUCH: Dr. Zobaida Eltazmany (Set
Up Phase).
8. Treatment of Allergic Rhinitis in AUCH: Dr. Shahinaz (Set Up Phase).

53. Alexandria CEBCPGs
Adapted ADAPTE
Methods
for CPGs adaptation

54. 5 Finalized Adapted CPGs

55. Official website:
http://www.alexmed.edu.eg/?page_id=1278
Last accessed 8/2012

56. https://www.facebook.com/pages/Alexandria-Center-for-Evidence-Based-Clinical-Practice-
Guidelines/124300224291530?ref=hl

57. Prof. Dr. Nabil Dowidar
Professor of General Surgery , MRI
Head, Alexandria Center for EBM, MRI
Founding Member, Health Governance Unit, MRI
Former Dean, MRI
Medical Research Institute (MRI)
Prof. Dr. Afaf Ibrahim
Professor of Public Health, Social & Preventive Medicine, AFM
Head, Community Medicine Dept.
Director, CEBCPGs , HCQD-AUHs

58. Dr. Yasser Sami Amer
M.Sc. Pediatrics, M.Sc. Healthcare Informatics
Hospital Clinical Guidelines & Pathway General Coordinator, CEBCPGs, HCQD-AUHs, Primary
Contact Person for G-I-N
Dr. Hossam Dhorgham
M.Sc. Pediatrics, M.Sc. Healthcare Management
Former Healthcare Quality Coordinator, HCQD-AUHs
Former Head, Accreditation & Licensure Directorate, HCQD-AUHs
Eng. Ahmed Mourady
Communication & Electronics Engineer
E-Learning Consultant,
Former Local Project Manager, Modernization of AUHs in Smouha

59. Prof. Dr. Tarek Omar
Professor of Pediatrics & Ped. Neurology, AFM
General Supervisor CEBCPGs & HCQD-AUHs.
Former Head, AUHs Sector

60. Prof. Dr. Mahmoud El-Zalabany
Professor of Pediatrics & Ped. Respiratory, Allergy & Immunology
Former Dean, AFM
Former Chairman, AUHs Board

61. G-I-N 2009 Lisbon
G-I-N 2012 Berlin

62. Dr. Yasser Sami Amer
MSc Pediatrics, MSc HC Informatics
EBCPGs Advisor & Trainer