Developing valid cost effectiveness guidelines: a methodological report from the north of England evidence based guideline development project

Evidence-based core information for health communication of tobacco control: The effect of smoking on risks of female disease

Objective

Cigarettes have become the the biggest killer of contemporary female's health and beauty. What kind of health information is suitable for the general public is an important issue to be discussed globally. The purpose of this study is to generate systematic, rigorous, public-demand-oriented and appropriate core information relevant to tobacco control based on the best available evidence, combined with audience preferences and pre-dissemination content review from multidisciplinary expertise in order to improve the effectiveness of health communication of tobacco control.

Methods

Relevant systematic reviews meta-analysis that reported smoking on risks of female disease were identified by searching PubMed, Embase, the Cochrane Library, Web of Science, Clinical Trials.gov, and the International Clinical Trial Registry Platform. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) process was applied to assess the evidence in order to make rigorous core information. The audience prevalence survey was conducted to ensure that core information was targeted and tailored. Finally, the expert assessment was used for a pre-dissemination content review and to evaluate whether the core information was appropriate or not.

Results

The final core information consisted of eight parts concerning the effects of smoking and female cardiovascular disease, diabetes, rheumatoid arthritis, respiratory disease, digestive system disease, mental disease, non-pregnant female reproductive system disease, as well as pregnant women and their fetuses. A total of 35 items of core information suitable for dissemination was included and the quality of evidence, the degree of public demand and the outcome of pre-dissemination content review were reported.

Conclusion

The core information related to female cardiovascular system diseases, as well as liver cancer and upper gastrointestinal cancer is the preferred content for health communication of tobacco control. The quality of evidence for core information related to pregnant women and their infants, as well as diseases of reproductive system, respiratory system, and diabetes needs to be improved to meet high public demand. The core information related to mental disease is more suitable for dissemination to patients with mental illness than to the general public. Besides, dissemination of core information should be individualized. Evidence-based Core Information for Health Communication of Tobacco Control would be helpful to provide evidence support for health communication related to tobacco control and enhance public health literacy for international communities that have high smoking prevalence and related disease burden.

[How should health and healthcare priorities be set and evaluated? Prioritization methods and regional disparities. 2008 SESPAS Report]

The conflict between scarce resources and unlimited needs is perhaps more prominent in the healthcare sector than in any other areas. Thus, setting priorities in health care emerges as an unavoidable task. The laudable aim of adopting any health technology that improves the population's health is impossible when confronted by budgetary constraints. Therefore, the outstanding health problems of a society and the most efficient health technologies in terms of their cost-effectiveness must be identified and patients must be prioritized, bearing in mind aspects of equity and efficiency. The present article reviews the issue of setting health care priorities by examining the experiences that have been put into practice in Spain and abroad. The problem is analyzed at three levels: the "macro" level (strategic planning, identification of higher priority areas and the selection of health care interventions); the "meso" level (incorporation of cost-effectiveness analyses into clinical practice guidelines), and the "micro" level (how to design priority systems for patients on waiting lists based on clinical and social criteria). In all these levels, there is substantial heterogeneity between Spanish regional health services, the steps that need to be taken and the ground that needs to be covered. Thus, we suggest that the first steps that some regional health services have made, together with international initiatives, could serve as a reference for the definitive incorporation of new approaches in priority setting in the Spanish health system as a whole.

A new method of analysis enabled a better understanding of clinical practice guideline development processes

OBJECTIVE

To describe the process by which various forms of evidence are discussed, valued, and interpreted within the process of developing evidence-based clinical practice guidelines and, in so doing, to develop a method for such studies.

STUDY DESIGN AND SETTING

An observational study. Two guideline development groups were observed by a nonparticipant observer. The 21 meetings were recorded, transcribed, and analyzed using grounded theory and frame analysis. Qualitative analysis was complemented with descriptive statistics.

RESULTS

The groups organized their discussion around four domains--'science', 'practice', politics', and 'process'--and used boundary work to mediate between these domains. Both groups spent most time discussing 'science', followed by 'practice' or its relation with 'science'.

CONCLUSION

Our analysis offers an innovative, replicable method of analysis of guideline development that permits the identification of the proportions and interrelations between knowledge domains deployed by guideline groups. This analysis also suggests that the participation hierarchy observed here and by others might be an effect of the imbalanced use of knowledge domains in the construction of clinical guidance. This constitutes an important framework to understand the interplay of participants and knowledge in guideline development.

Incorporating information about cost-effectiveness into evidence-based decision-making: the evidence-based practice center (EPC) model

RATIONALE

There is a pressing need for guidance on how to incorporate economic information into evidence-based decision-making. Such guidance should take account of the quality and relevance of economic evaluations.

OBJECTIVE

To summarize lessons learned in integrating information from decision analyses and cost-effectiveness analyses.

KEY ISSUES

Several methods used by the Evidence-Based Practice Centers (EPCs) to conduct systematic reviews are applicable to assessing economic studies. We discuss methods to identify key questions for the review of economic studies. Reviews should assess how an economic model incorporates clinical logic and handles uncertainty about effectiveness. As is the case for metaanalysis of interventions, qualitative or quantitative synthesis of economic studies should explore heterogeneity to identify key uncertainties underlying divergent results as well as unsuspected sources of bias.

CONCLUSIONS

Applying EPC methods to synthesis of economic information can increase their relevance to clinicians and policymakers and inform decisions that require tradeoffs between effectiveness and harms of interventions.

Methods and criteria used in evidence-based decisions in public health

A workshop entitled, "The Impact of Maternal Thyroid Diseases on the Developing Fetus: Implications for Diagnosis, Treatment, and Screening," was held in Atlanta, Georgia, January 12-13, 2004. This paper reports on the session that examined methods and criteria used for decisions in public health. For this session the following papers were presented: "Methods to Evaluate Scientific Evidence," "Criteria for Screening," and "Public Health Considerations." Development of evidence-based guidelines, strengthened by rigorous systematic reviews, will improve the quality, efficiency, and cost effectiveness of management of thyroid dysfunction among reproductive-age women. Maternal and fetal benefits that have been hypothesized to result from screening pregnant and pre-pregnant women for hypothyroidism include reduced incidences of peripartum maternal complications and fetal loss and optimization of fetal and neonatal neuropsychological development. Screening should be considered as the initial step in a comprehensive program that includes appropriate diagnostic and therapeutic interventions. The actual benefits and potential risks (i.e., iatrogenic thyrotoxicosis) of implementing a thyroid function screening program have not been demonstrated in a prospective randomized clinical trial or prospective cohort study. Consequently, it is difficult to develop consensus and secure resources for a comprehensive thyroid function screening and therapeutic intervention program in women who are or anticipate becoming pregnant. Marshalling support for performance of both a clinical trial and high-quality observational studies should be a high priority.

Development and use of evidence-based clinical practice guidelines for thyroid disease

Clinical practice guidelines offer recommendations for optimizing health care. Guideline panels can rely on several methods for gathering information about current practice and synthesizing evidence that addresses specific questions. Clinical practice guidelines, including many that address thyroid disease, often rely on conventional narrative literature reviews and expert opinion rather than systematic evaluation of the published literature as the basis for their recommendations. This undermines the authority of practice guidelines and potentially results in disparate, invalid, or misleading recommendations. In contrast, incorporation of rigorous systematic reviews of literature and guidance by groups with multidisciplinary expertise decreases bias in evidence selection and increases precision of treatment effect estimates. Improved reliability and accuracy of evidence assessment, in turn, strengthens ultimate guideline recommendations. Cost-effective analyses further contribute to useful clinical practice guidelines and may encourage the explicit acknowledgment of values and preferences. Valid recommendations, however, prove futile in the absence of implementation. Adherence to guidelines may be improved with integration of user-friendly computer applications into clinical practice. By overcoming barriers to implementation and addressing the limitations of current guidelines, endocrinologists can play an essential role in improving the quality, efficiency, and cost-effectiveness of clinical practice related to thyroid disorders.

Use of echocardiography among patients with heart failure: practice variations in Hungarian hospitals

OBJECTIVE

To evaluate some factors, such as demographic factors, disease severity, dissemination of practice guidelines, and hospitals providing medical care, influencing the use of echocardiography among patients with congestive heart failure.

DESIGN

A 'before-after' controlled epidemiological study based on hospital documentation.

SETTING AND PARTICIPANTS

A total of 1222 admitted patients with a diagnosis of chronic heart failure from six voluntarily participating hospitals representing each level of in-patient care in Hungary.

INTERVENTIONS

Implementation of clinical practice guidelines about heart failure developed by the US Agency for Health Care Policy and Research.

RESULTS

The echocardiography was performed in slightly more than 50% of all cases in the total. The use of echocardiography was different according to age, sex, and hospitals, but no significant difference was found in disease severity and between the two periods of time (before and after the dissemination of the guidelines).

CONCLUSIONS

This study reveals the existing differences in the use of echocardiography and the lack of essential changes after the dissemination of the guidelines. The distribution and implementation of guidelines needs further investigation.

Development of guidelines to facilitate improved support of South Asian carers by primary health care teams

BACKGROUND

Evidence based guidelines are regarded as an appropriate basis for providing effective health care, but few guidelines incorporate the views of users such as carers.

AIM

To develop guidelines to assist primary health care teams (PHCTs) in their work with carers within South Asian communities.

METHODS

The guidelines were drawn up by a development group consisting of members of teams in areas with South Asian communities (Leicester and Bradford). The teams were invited to make their recommendations based on a systematic review of literature on minority ethnic carers and the findings of a study of the needs and experiences of local South Asian carers. A grading system was devised to enable the teams and a group of expert peer reviewers to assess the quality of evidence in support of each recommendation.

RESULTS

The teams agreed seven recommendations, graded according to available evidence and strength of opinion. External peer review supported the PHCTs' interpretation of evidence and their recommendations. The recommendations included consideration of communication and information for carers, coordination of care within teams, and recognition by team members of the roles of carers and their cultural and religious beliefs.

CONCLUSION

There are particular steps that PHCTs can take to improve their support of South Asian carers. It is possible to develop guidelines that take users' views into account and incorporate evidence from qualitative studies.

Development of guidelines to facilitate improved support of South Asian carers by primary health care teams

BACKGROUND

Evidence based guidelines are regarded as an appropriate basis for providing effective health care, but few guidelines incorporate the views of users such as carers.

AIM

To develop guidelines to assist primary health care teams (PHCTs) in their work with carers within South Asian communities.

METHODS

The guidelines were drawn up by a development group consisting of members of teams in areas with South Asian communities (Leicester and Bradford). The teams were invited to make their recommendations based on a systematic review of literature on minority ethnic carers and the findings of a study of the needs and experiences of local South Asian carers. A grading system was devised to enable the teams and a group of expert peer reviewers to assess the quality of evidence in support of each recommendation.

RESULTS

The teams agreed seven recommendations, graded according to available evidence and strength of opinion. External peer review supported the PHCTs' interpretation of evidence and their recommendations. The recommendations included consideration of communication and information for carers, coordination of care within teams, and recognition by team members of the roles of carers and their cultural and religious beliefs.

CONCLUSION

There are particular steps that PHCTs can take to improve their support of South Asian carers. It is possible to develop guidelines that take users' views into account and incorporate evidence from qualitative studies.

The socio-organizational age of artificial intelligence in medicine

The increasing pressure on Health Care Organizations (HCOs) to ensure efficiency and cost-effectiveness, balancing quality of care and cost containment, will drive them towards a more effective management of medical knowledge derived from research findings. The relation between science and health services has until recently been too casual. The primary job of medical research has been to understand the mechanisms of disease and produce new treatments, not to worry about the effectiveness of the new treatments or their implementation. As a result many new treatments have taken years to become part of routine practice, ineffective treatments have been widely used, and medicine has been opinion rather than evidence based. This results in suboptimal care for patients. Knowledge management technology may provide effective approaches in speeding up the diffusion of innovative medical procedures whose clinical effectiveness have been proved: the most interesting one is represented by computer-based utilization of evidence-based clinical guidelines. As researchers in Artificial Intelligence in Medicine (AIM), we are committed to foster the strategic transition from opinion to evidence-based decision making. Reviews of the effectiveness of various methods of guideline dissemination show that the most predictable impact is achieved when the guideline is made accessible through computer-based and patient specific reminders that are integrated into the clinician's workflow. However, the traditional single doctor-patient relationship is being replaced by one in which the patient is managed by a team of health care professionals, each specializing in one aspect of care. Such shared care depends critically on the ability to share patient-specific information and medical knowledge easily among them. Strategically there is a need to take a more clinical process view of health care delivery and to identify the appropriate organizational and information infrastructures to support this process. Thus, the great challenge for AIM researchers is to exploit the astonishing capabilities of new technologies to disseminate their tools to benefit HCOs by assuring the conditions of knowledge management and organizational learning at the fullest extent possible. To achieve such a strategic goal, a guideline can be viewed as a model of the care process. It must be combined with an organization model of the specific HCO to build patient careflow management systems. Artificial intelligence can be extensively used to design innovative tools to support all the development stages of those systems. However, exploiting the knowledge represented in a guideline to build them requires to extend today's workflow technology by solving some challenging problems.

Involvement of consumers in the development of evidence based clinical guidelines: practical experiences from the North of England evidence based guideline development programme

BACKGROUND

Consumer involvement in clinical guidelines has long been advocated although there are few empirical accounts of attempts to do so. It is therefore not surprising that there is a lack of clarity about how and when to involve consumers and what to expect from them within the process of guideline development.

METHODS

The North of England evidence based guideline development programme has used four different methods of consumer involvement.

RESULTS

When individual patients were included in a guideline development group they contributed infrequently and had problems with the use of technical language. Although they contributed most in discussions of patient education, their contributions were not subsequently acted on. In a "one off" meeting with a group of patients there were again reported problems with medical terminology and the group were most interested in sections on patient education and self management. However, their understanding of the use of scientific evidence in order to contribute to a more cost effective health care remained unclear. In a workshop it was possible to explain the technical elements of guideline development to patients who could then engage with such a process and make relevant suggestions as a consequence. However, this was relatively resource intensive. A patient advocate within a guideline development group felt confidence to speak, was used to having discussions with health professionals, and was familiar with the medical terminology.

CONCLUSIONS

Consumers should be involved in all stages of guideline development. While this is possible, it is not straightforward. There is no one right way to accomplish this and there is a clear need for further work on how best to achieve it.