Working with Guidelines
Working with Guidelines
This month, MGP’s Ivor Eisenstadt looks at how consensus guidelines are viewed by healthcare professionals, the importance of understanding the PCO guidelines agenda and the ways in which PCOs would like to be supported in guideline implementation.
Consensus guidelines are often developed to provide evidencebased recommendations in clinical areas where there is a lack of national guidance available. For example, the National Osteoporosis Guideline Group (NOGG), a group of experts in the field of osteoporosis, recently published a guideline on prevention and treatment of osteoporosis (see Box 1 for a summary). This guideline was developed for a number of reasons:
• There had been long delays in the NICE development programmes for its two technology appraisals on the primary and the secondary prevention of osteoporotic fractures, and also its clinical guideline on osteoporosis.
• There were concerns that, due to the delays, the guidelines would exclude some newer treatments, information on certain types of patients, and also details of the WHO-supported approach to the assessment of fracture probability (FRAX®). NOGG developed its guideline to fill the gap in osteoporosis guidance available. NICE has subsequently published its two technology appraisals (Boxes 2 & 3) but the clinical guideline is still awaited.
Do healthcare professionals value consensus guidelines?
MGP attempted to answer this question with a readership survey sent to the Guidelines audience, which was conducted in June 2008. Guidelines is a publication that is sent to over 40,000 permanently placed GPs and pharmaceutical advisers, and includes summaries of all the major primary care guidelines from NICE, the Department of Health, independent professional bodies, and consensus groups. The consensus guidelines are frequently sponsored by the pharmaceutical industry, but have to meet strict criteria relating to the make up of the working party and independence from the sponsorship.
In the survey, readers were asked, ‘When do you find working party/ consensus guidelines to be most useful?’ Results analysed from the first 500 respondents showed that consensus guidelines were thought to be most useful when national guidelines are unclear (51%), when there are no national guidelines (47%), and when national guidelines are too broad (39%). Only 5% of respondents found working party/ consensus guidelines to be ‘not useful’.
| Box 1: Guidelines for the diagnosis and management of osteoporosis in postmenopausal women and men from the age of 50 years in the UK |
Guidance type: National Osteoporosis Guideline Group (NOGG) clinical guideline
Date issued: October 2008
Web site: http://www.shef.ac.uk/NOGG/
Summary
The guideline is based on an opportunistic case finding strategy in which physicians are alerted to the possibility of osteoporosis and high fracture risk by the presence of clinical risk factors (CRFs) associated with fracture. Briefl y the guideline states that:
• Postmenopausal women with a prior fragility fracture should be considered for treatment without the need for further risk assessment, although BMD measurement may sometimes be appropriate, particularly in younger postmenopausal women.
• Assessment by the FRAX tool should be undertaken in:
- Men aged 50 years or more (with or without fracture) but with a WHO risk factor or a BMI < 19kg/m².
- All postmenopausal women without fracture but with a WHO risk factor or a BMI < 19kg/m².
Following the assessment of fracture risk using FRAX, the patient may be classified to be at low, intermediate or high risk.
• Low risk - reassure and reassess in fi ve years or less depending on the clinical context.
• Intermediate risk - measure BMD and recalculate the fracture risk to determine whether an individual’s risk lies above or below the intervention threshold.
• High risk - can be considered for treatment without the need for BMD, although BMD measurement may sometimes be appropriate, particularly in younger postmenopausal women. |
| Box 2: Osteoporosis - primary prevention |
Box 3: Osteoporosis - secondary prevention including strontium ranelate |
Alendronate, etidronate, risedronate, raloxifene and strontium ranelate for the primary prevention of osteoporotic fragility fractures in postmenopausal women
Guidance type: NICE Technology appraisal
Date issued: October 2008
Expected Review Date: NICE will consult on their review plans for this guidance in July 2010.
Web address: http://www.nice.org.uk/Guidance/TA160/Guidance/pdf/English |
Alendronate, etidronate, risedronate, raloxifene, strontium ranelate and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women.
Guidance type: NICE Technology appraisal
Date issued: October 2008
Expected Review Date: NICE will consult on their review plans for this guidance in July 2010.
Web address: http://www.nice.org.uk/Guidance/TA161/Guidance/pdf/English |
The same research asked, ‘At what stage(s) during a patient consultation do you use Guidelines?’. Respondents answered: Informing the management decision (80%); diagnosis (79%); review/ongoing management (71%); and confirming prescribing decision (29%).
Readers were also asked: ‘In what other ways do you and your practice/organisation use Guidelines? The results were: Keeping up to date (80%); managing individual patients (55%); training and education (44%); implementing national guidance (34%); developing local guidelines (28%); and prescribing formulary development (14%).
These results provide good evidence that clinical guidance, including consensus guidelines, influences clinical decisions and is valued by healthcare professionals.
Understanding the PCO guideline agenda
To support your customers you need to not only be aware of their views on the value of clinical guidance but also on the local PCO guideline agenda in your disease area. There is a variety of information that can help you to understand the PCO guideline agenda, for example, the results from the Pharmaceutical Advisers and Medicines Management tracker (PAMMtrak) survey, which is carried out twice yearly by MGP and Brainsell.
The most recent survey generated responses from 100 pharmaceutical advisers and medicines management professionals working in 86 separate PCOs. It provides insight in to their key issues, and tracks which medicines management initiatives are proving most effective across a range of disease areas. Below are some examples of the type of information obtained from the PAMMtrak survey for the management of osteoporosis:
• When asked, ‘What had the most influence over product choice on local osteoporosis clinical guidance at your PCO?’, respondents reported: national guidance (43%); cost effectiveness (29%); efficacy (11%); safety (7%); Regional Prescribing Centres (e.g.: MTRAC)(4%).
• 53% of respondents reported that national guidelines had the greatest influence over prescribing choice at their PCO.
• 15% of respondents reported that local guidelines had the greatest influence over prescribing choice at their PCO.
• 25% of respondents reported that national guidelines and local guidelines had equal influence over prescribing choice at their PCO.
• 22% of respondents said osteoporosis is a priority at their PCO.
• 53% reported their PCO had a prescribing formulary for osteoporosis.
• 36% stated that their PCO had introduced local prescribing guidelines for osteoporosis.
Another of the PAMMtrak questions asked respondents to ‘Indicate how effective actions/initiatives had been for ensuring compliance with formularies and prescribing guidelines’. The results highlighted in figure 1 show the range of actions/initiatives that were seen as being effective, with medicines management and practice visits rated the most effective.
Supporting the guidelines agenda
The survey also asked whether respondents would like additional support with actions/initiatives to ensure compliance with formularies and prescribing guidelines. The results in figure 2 show that educational meetings is the area where support is most desired and is of course an area where the industry is in a particularly strong position to help.
Knowing the multiple factors that influence the clinical decisions of the PCOs and practices that you work with is essential. Being aware of their views on the support that they require for their actions and initiatives is also important. It is through understanding how you can provide the most appropriate support that you will identify and develop win/win relationships.
Ivor Eisenstadt is Managing Director of MGP, the publishers of Guidelines, Guidelines in Practice and Medendium. Its medical education division, Connectmedical, provides opportunities for companies to support healthcare professionals in their pursuit of best practice.
For further details contact Ivor on 01442 876100 or email: ivor.eisenstadt@mgp.ltd.uk |